Tlc Base Financial Disclosure Form
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1
2Licensing Division
nd
32-02 Queens Boulevard, 2
Floor
Long Island City, New York 11101-2324
Tel: 212.227.6324, Fax: 718.391.5695
TLC BASE FINANCIAL DISCLOSURE STATEMENT
page 1 of 2
This must be submitted – COMPLETED – with your application. This should reflect the finances of the BUSINESS ENTITY.
Business Name:
D/B/A:
Address:
EIN # or SSN#:
Base Phone #:
$
2
0
Lease Expires :
M
M
D
D
Lease Amount
NAME OF PARTNERS OR OFFICERS / STOCKHOLDERS AND AMOUNT OWNED
(Shares - Please list actual numbers, not percentages)
1. __________________________________________________ # _____ 2. __________________________________________________ # _____
3. __________________________________________________ # _____ 4. __________________________________________________ # _____
BANK REFERENCES
Bank 1 Name:
Address:
Officer’s Name:
Bank Phone #:
Account Type:
Bank 2 Name:
Address:
Officer’s Name:
Bank Phone #:
Account Type:
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