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Column A: If Yes, columns B through J do not need to be filled in. Proceed to column K.
Is the Operator also the Owner? |
Column B: Name of Operator's establishment
Operator Name
(i.e., Company or Individual Operator Name) |
Column C: Enter address
Address Line 1 |
Column D: Enter additonal address information
Address Line 2 |
Column E: Enter city of Operator's establishment
City |
Column F: Enter State of Operator's establishment
State |
Column G: Enter post office or zip code of operator's establishment
Post Office or Zip Code |
Column H: Enter 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 Operator) |
Column I: Enter alternate name that is used for your busines
Alternate Business Name |
Column J: Enter the business structure association with your establishment
Select from the following options:
Sole Proprietorship
Partnership
Corporation
Business Structure
(of the Operator) |
Column K: If a partnership, enter all partners separated by a semi-colon.
If a corporation, enter all corporate offices and director separated by a semi-colon.
If Partnership, list Partners
If Corporation, list Corporate Officers and Director
Separate each individual using a semicolon " ; " |
Column L: If a corporation, select state of incorporation.
If Corporation, State of Incorporation |
Column M: If a corporation and if not incorporated as a U.S. state, select state or territory of incorporation.
If Corporation, and if not incorpoated as a U.S. State, describe further |
Column N: Identify whether the primary establishment has the same name or address as the Operator's. If it does, columns N through V do not need to be filled
Is the Establishment Name/Address same as Operator? (Y/N) |
Column O: 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 P: Enter establishment's address
Address Line 1 |
Column Q: Enter additional address details
Address Line 2 |
Column R: Enter establishment city
City |
Column S: Enter establishment state
State |
Column T: Enter establishment post office or zip code
Post Office or Zip Code |
Column U: Enter establishment telephone number
Telephone Number |
Column V: Enter establishment fax number
Fax Number |
Column W: 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 X: Enter operations performed by the establishment
Operations Performed by the Establishment |
Column Y: If "Other..." is selected as an operation, please provider further details
If Other, please describe |