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Your Name

Your Email Address

Trade Name of Business

Owner Name (entity if corporation)

Name of all owners/persons involved

Type of Permit needed

Address of Business

City of Business

State of Business

Mailing Address to receive permits

Your Phone Number

Property Owner name

Lease information – monthly payment

Lease information – expiration date

Total Investment in Business

Projected Sales Figures

Projected Opening date

Distance to nearest School

Distance to nearest Church

Distance to nearest Day Care

Distance to nearest Residence

Distance to nearest Hospital

Additional Comments

Security code