Column A: Enter the establishment name if it is not the same as the Operator's name
Establishment Name
(i.e., Company or Individual Establishment Name) |
Column B: Enter establishment's address
Address Line 1 |
Column C: Enter additional address details
Address Line 2 |
Column D: Enter establishment city
City |
Column E: Enter establishment state
State |
Column F: Enter establishment post office or zip code
Post Office or Zip Code |
Column G: Enter establishment telephone number
Telephone Number |
Column H: Enter establishment fax number
Fax Number |
Column I: Enter establishment's Dun and Bradstreet number. The D-U-N-S Number is a unique nine digit identification number, for each physical location of your business.
D&B DUNS #
(of the Establishment) |
Column J: Enter operations performed by the establishment
Operations Performed by the Establishment |
Column K: If "Other..." is selected as an operation, please provider further details
If Other, please describe |