Legal Business Name

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Trade Name / DBA (if applicable)

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Business Entity Type

LLC

Corporation

Nonprofit

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Other

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State of Formation

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Date Business Was Formed (if existing)

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Business Physical Address

Address

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City

State

Zip

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Business Mailing Address (if different)

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Full Name of Business Owner

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Title/Position

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Phone Number

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Email Address

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Preferred Method of Contact

Email

Phone

Text Message

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Is your business currently using a Registered Agent?

Yes

No

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If Yes, who is your current Registered Agent?

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Are you requesting:

New Registered Agent Service

Change of Registered Agent

Renewal of Registered Agent Service

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In which state(s) do you need Registered Agent services?

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Has your business received any compliance notices or state correspondence?

Yes

No

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If Yes, please explain:

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Who should receive important state notices and legal documents?

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Email Address for Compliance Notifications

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Would you like compliance reminder notifications?

Yes

No

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Are you interested in any of the following services?

LLC Formation

EIN Filing

Annual Report Filing

Business Compliance Assistance

Operating Agreement Preparation

Virtual Assistant Services

None at This Time

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Acknowledgement

I certify that the information provided above is accurate and complete to the best of my knowledge.

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Client Name

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Date

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