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Vendor License Renewal Application Form

  1. Business Information *
    Provide local business & corporate information
  2. This number is provided to you in your notice.
  3. Preffered Mailing Address*
  4. Ownership – Principals, Sole Owners, Shareholders, Partners, etc.
  5. If you have additional owners, please attach a listing.
  6. Machine Information
    Please provide information for each machine licensed.
  7. If you have more machines, please attach a listing.
  8. Execute*
    By selecting I agree option below you are giving your electronic signature.
  9. No False statements
    Your submission of this form certifies that the information provided is true and correct.
  10. Information for individual completing this form.
  11. Leave This Blank:

  12. This field is not part of the form submission.