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2. Name of Business or Organization*
4. Sales Tax Number*
6. Owner First Name*
7. Owner Last Name*
9. Address*
11. City*
12. State*
13. Zip Code*
15. Phone Number*
16. Email Address*
18. Description of Business and Goods to be Sold*
20. Dates of Business or Solicitations *
    Dates of Business or Solicitations Start Date

    —

    Dates of Business or Solicitations End Date
22. Representatives Making Sales or Solicitations
24. Valid Photo Identification must be Uploaded for ALL Representatives**
26. First Name*
27. Last Name*
29. Address*
31. City*
32. State*
33. Zip Code*
35. Description of Vehicle: Color/Make/Model *
37. License Plate Number*
38. State Issued*
39. Owner of Vehicle*
41. First Name
42. Last Name
44. Address
46. City
47. State
48. Zip Code
50. Description of Vehicle: Color/Make/Model
52. License Plate Number
53. State Issued
54. Owner of Vehicle
56. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
58. Electronic Signature*
59. Completion Date*
    Completion Date
Leave This Blank:


61. 1. Receive an email copy of this form.
62. Email address

    This field is not part of the form submission.

63. Submit Submit and Print

* indicates a required field