Company Name ______________________________
Billing Address ______________________________
Phone ___________________ Fax:________________ Telex:_______________
e-mail Address ______________________________
____ Corporation ____ Partnership ____ Proprietorship ____Other
Type of Business _______________________
Year established __________ Yearly Gross Sales $ ______________________________
Yearly Net Profits $ ______________________________
Net Value $ ______________________________
NAMES AND ADDRESSES OF OWNERS, PARTNERS, OR OFFICERS:
Name ______________________________
SS # ______________________________
Title ______________________________
Address ________________________________________________________________
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