Date:

COMPANY INFORMATION:
Business Name:
Address:
Phone #:  Fax#   E-mail
Contact Person & Title:  

DESCRIPTION OF COMPANY:
Corporation                      Subsidiary of
Proprietorship                  Individual      Partnership

FINANCIAL INFORMATION:
Date organized or incorporated
Please list owners, partners, or officers:

DESCRIPTION OF EACH PRODUCT TO BE REQUESTED TO BE LICENSED:
(INCLUDE EXAMPLES)

PRODUCTS CURRENTLY MANUFACTURED AND/OR DISTRIBUTED

BANK REFERENCES:
Bank:
Address:
Phone:
Contact Person:

OTHER LICENSES: