Form

Contact information of Applicant

Name

Phone Number

Email Address

Address

Address Line 2

City

State

Zip

For LLC

Entity Name

Service of Process Address to be Listed With NYS (after Albany)

Address

Address Line 2

City

State

Zip

County to be Listed With NYS (after Albany)

Name of Organizer

For EIN

Single or Multi Member?

Single

Multi

Name of Responsible Party (only one may be listed)

SSN of Responsible Party

Physical Business Address

Address

Address Line 2

City

State

Zip

Mailing Address (if different than physical; can also be a virtual address)

Address

Address Line 2

City

State

Zip

Phone Number for IRS Records

Brief Description of Business Activity

For BOI

Beneficial Owner

Name(s) of Beneficial Owners

Address(s) of Beneficial Owner

Address

Address Line 2

City

State

Zip

Principal Place of Business

Address

Address Line 2

City

State

Zip

Form

Contact information of Applicant

For LLC

Service of Process Address to be Listed With NYS (after Albany)

County to be Listed With NYS (after Albany)

Name of Organizer

For EIN

Single or Multi Member?

Name of Responsible Party (only one may be listed)

SSN of Responsible Party

Physical Business Address

Mailing Address (if different than physical; can also be a virtual address)

Phone Number for IRS Records

Brief Description of Business Activity

For BOI

Beneficial Owner

Address(s) of Beneficial Owner

Principal Place of Business

Copy of Photo ID (driver license or passport)