MAILING ADDRESS (IF DIFFERENT): Contact Person: ____________________________________________________
Street Address: __________________________________________________________________________________
City ______________________________State _______ Zip______________ Phone: __________________________
Fax: ______________________________ Email Address: ________________________________________________
COMPLETE INFORMATION BELOW AND PROVIDE COPIES OF EACH, WHERE APPLICABLE:
Alabama Sales and Use Tax#: ____________________________Federal Tax ID#: _____________________________
Shelby County Health Permit#: ___________________________ABC License #: ______________________________
State of AL Master Electrical Card#: _______________________State of AL Master Plumbers Card: ______________
State of Alabama HVAC Card#: ___________________________Residential Home Builder Card#: ________________
ALABAMA State General Contractor#: _______________________
Select the Type of Organization: (Inc., LLC. LLP, Proprietorship, etc.) (Please provide probated copy of Articles of
Formation)
Sole Proprietorship
Other (Specify) ____________________________________________________
Name/Address of ALL officers of Entity: (Attach Additional Sheets if necessary):
Name
Address
Title
Phone#
Social Security#
____________________ _______________________ _____________ _______________ ___________________
____________________ _______________________ _____________ _______________ ___________________
____________________ _______________________ _____________ _______________ ___________________
____________________ _______________________ _____________ _______________ ___________________
____________________ _______________________ _____________ _______________ ___________________
I _______________________________hereby certify that all information given is true and correct.
Printed Name
_______________________________________________
_________________________
Signature
Date