Form Bls-700-028 Mba - Master Application Page 2
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43. Business Information
a.
Check only one box in this section that applies to your ownership structure:
!
!
!
Sole Proprietor: If married, should spouse’s name appear on license?
Yes
No
(
If you answer No, you must still enter the
)
.
spouse information in Section C below
!
!
!
!
Partnership
Limited Partnership
Limited Liability Partnership
Limited Liability Compan y
!
!
!
Washington Corporation
Out of State Corporation
Non Profit Corporation
(educational, religious, charitable )
Partnership, Corporation, LLC or LLP Name
State incorporated/formed:
Year incorporated/formed:
!
!
!
!
Association
Trust
Municipality
Other
Name of Organization
b.
____________
/
Business Open Date
If unknown, please estimate.
MM
YY
!
!
Inside city limits?
Yes
No
Doing Business As (DBA) /Trade Name
County in Which Business is Located
Business Mailing Address (Street or PO Box, Suite No. Do not use building name)
Business Street Address
in Washington (if different than mailing address)
City
State
Zip
City
State
Zip
(
)
(
)
Business Telephone Number
Fax Number
Internet/E-Mail Address
c.
List all owners & spouses: Sole proprietor, partners, officers, and LLC members. Attach additional pages if needed.
" " " " "
(
)
Name (Last, First, Middle)
Title
Home Telephone Number
Are you married? ! Yes ! No If yes, enter spouse information below.
Home Address (Street or PO Box)
City
State
Zip
Spouse’s Name (Last, First, Middle)
/
/
/
/
Date of Birth
Spouse Social Security Number
Social Security Number
% Owned
Spouse Date of Birth
" " " " "
(
)
Home Telephone Number
Title
Name (Last, First, Middle)
Are you married? ! Yes ! No If yes, enter spouse information below.
Home Address (Street or PO Box)
Spouse’s Name (Last, First, Middle)
City
State
Zip
/
/
/
/
Spouse Date of Birth
Spouse Social Security Number
Social Security Number
Date of Birth
% Owned
" " " " "
(
)
Home Telephone Number
Title
Name (Last, First, Middle)
Are you married? ! Yes ! No If yes, enter spouse information below.
Home Address (Street or PO Box)
Spouse’s Name (Last, First, Middle)
City
State
Zip
/
/
/
/
Date of Birth
Social Security Number
Spouse Social Security Number
Spouse Date of Birth
% Owned
The Social Security Number is required for all sole proprietors (RCW 26.23,150) and for all owners and spouses of a business that will
have liquor, lottery or private investigator licenses. Not providing this information will result in application delays.
Please continue Business Information on page 3.
BLS-700-028 MBA (R/06/06) OR/W Page 2 of 4
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