Odoj Telephonic Seller Registration Form Page 2

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FOR OFFICIAL USE ONLY
1.
Date Registration Submitted:
MM
DD
YY
2.
Registration Period Valid for 1 year beginning on:
MM
DD
YY
This filing is made on behalf of:
3.
(The name that will be used when contacting the public)
We also do business under the following names:
4.
Legal Name of your Business:
Please provide a brief description of what you sell:
5.
Corporation or LLC
Our business is a
; we are registered in:
Select a State
A)
(List the State in which you are incorporated or organized)
Our business is a Partnership ; under the laws of:
Select a State
B)
(List the State in which the Partnership was founded)
Fictitious Business Name:
6.
Date the Name was Registered:
MM
DD
YY
C)
The Fictitious Business Name was registered by:
(Name of individual who registered the fictitious name)
The Fictitious Name was Registered in the State of:
Select a State
Please provide the complete street address of the principal location from which sales will be solicited:
7.
We will also be soliciting sales from the following address(es):
8.
Please provide your Mailing Address if different from the answer in question #7:
9.
If your business is listed as a Corporation, Limited Liability Company, Partnership or Proprietorship, the following information is
required for each Officer, Member, Director, Trustee, General Partner, Limited Partner, Sole Proprietor and Owner:
(Attach
additional pages if needed)
Name:
Date of Birth:
MM
DD
YY
Office Held:
Ownership Interest:
A)
Select a State
Driver's License #:
State of Issuance:
Complete Address of his/her principal residence:
Name:
Date of Birth:
MM
DD
YY
Office Held:
Ownership Interest:
10.
B)
Driver's License #:
State of Issuance:
Select a State
Complete Address of his/her principal residence:
Name:
Date of Birth:
MM
DD
YY
Office Held:
Ownership Interest:
C)
Select a State
Driver's License #:
State of Issuance:
Complete Address of his/her principal residence:
Justice-#5814656
ODOJ Telephonic Seller Registration Form
2 of 6
07/27/17

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