Form Ma - Master Application
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1
2MONTANA
Clear Form
Form MA
Rev 05 13
Master Application
Please check appropriate box(es) and complete all applicable information.
Current
UID number* ___________
Registration of a new One-Stop business.
Purchase of a One-Stop business. Effective date ________________ Previous owner’s UID number* __________
Addition of a new DBA (physical) location to a One-Stop business.
Addition of a new license to a One-Stop business.
Relocation to a new physical location.
Change of address. Is this a 911 change?
Yes
No
Corporate structure change.
* Your UID number (unique identifi er number) is located at the upper right-hand section of your One-Stop license or renewal.
Section I - Business Information
Company or Owner Name: ____________________________________________________________________________________
Federal Employer Identifi cation Number (FEIN) or Social Security Number: ______________________________
(Required)
______________________________________________________
_______________________
___________
___________
Business Mailing Address
City
State
ZIP + 4
Assumed business name/DBA/trade name, etc.: ___________________________________________________________________
______________________________________________________
_______________________
___________
___________
Business Location Address (cannot be a post offi ce box)
City
State
ZIP + 4
_____________________________________________
_____________________________
___________________________
County
Business Phone
Fax Number
E-mail address (optional): _____________________________________________________________________________________
Description of business transacted under the assumed business name: _________________________________________________
Type of business: (please check one and provide additional information as appropriate)
Individual
S corporation
Limited Liability Company
Association (attach names and addresses)
C corporation
Limited Liability Partnership (attach names and addresses)
Nonprofi t C corporation
Partnership (attach names and addresses)
Please complete Section II (other side of form), if applicable. In all situations, complete signature information.
Important:
All coordinating applications/affi davits must be completed and attached for processing.
License Fee Information is on other side of this form.
Signature
of sole proprietor, all partner(s), corporate offi cer(s), or limited liability manager(s) or member(s).
I (we), the undersigned, declare under the penalties of perjury and/or the revocation of any license granted, that I (we) am
(are) the applicant(s) or authorized representative(s) of the fi rm making this application and that the answers contained,
including any accompanying information have been examined by me (us) and that the matters and things set forth are true,
correct and complete.
Signature(s) required. If a corporation, corporate offi cer must sign.
Title
Date
____________________________________________________
__________________________
________________
____________________________________________________
__________________________
________________
____________________________________________________
__________________________
________________
Names and home addresses of all owners on the application are required. For corporations, the names and home addresses
of the corporation’s principal executive offi cers (president, vice-president, secretary and treasurer) and members of the
board of directors are required. (Attach additional sheet if necessary.)
Name
Home Address
Title
_____________________________________________
____________________________________
_____________
_____________________________________________
____________________________________
_____________
_____________________________________________
____________________________________
_____________
Please mail completed form to: One-Stop Licensing, PO Box 8003, Helena, MT 59604-8003
Questions? Call us toll free (866) 859-2254 (In Helena, 444-6900), FAX: (406) 444-0722
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Parent category: Business