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<br />Corporation - A person or group of people who <br />Incorporate by receiving a charter from their state's <br />Secretary of State Oncludes professional service <br />corporations). <br />Check one: 0 C-corporation <br />OS-corporation <br />o Not-for-profrt corporation <br />Umlted liability company - Two or marl! entitles (or <br />Individuals) who file articles of organization with their <br />state's Secretary of State. <br />Check one: 0 Single-member LLC <br />"'8Multi-member LLC <br />o Check here if you elected to be treated as a <br />corporation for federal income tax purposes. <br /> <br />If the business is a partnership, corporation, or limited liability company, provide your fiscal year <br />ending date: 1LIt2]/~[l] <br />month day <br />If the business is incorporated. chartered or otherwise registered to do business in Florida, <br />provide your document/registration number from the Florida Secretary of State: <br />G 0'8 f l.? -;t'i' 0 00 3S <br /> <br />'1" 10 I \ 1m lIlI\ 1\\1 \\ I III 111111 <br /> <br />9. <br />o <br />o <br /> <br />Type of ownership and legal organization (check one): <br /> <br />Sole proprietorship - An unincorporated business that is 0 <br />owned by one individual. <br /> <br />Partnership - The relationship existing between two or more <br />entities or individuals who join to carry on a trade or business. <br />This includes a business jointly owned/operated by a husband <br />and wife. <br /> <br />Check one: 0 General partnership <br /> <br />o Limited partnership ;g <br /> <br />o Joint venture <br /> <br />o Married couple <br /> <br />10. <br /> <br />11a. <br /> <br />Provide the date of incorporation, charter, or authorization to do business In Florida: <br /> <br />QJ[f]/[]~/ ~@]El[!] <br /> <br />month <br /> <br />day <br /> <br />year <br /> <br />11 b. If the business is incorporated in another state, provide the name of the state: <br />12. If the business is a corporation, provide the resident agent's contact information: <br />Resident agent's name: <br />Resident agent's street address: <br />Resident agent's City/StateIZIP: <br />Resident agent's telephone number Onclude area code) <br /> <br />DR-1 S <br />R.07/08 <br />Page 3 <br /> <br />Note: <br /> <br />If y.ou are not incorporated, <br />chartered or registered to do <br />business in Florida, you may <br />. be requlred to do so. For more <br />. Information, go to the Florida <br />Department of State's Intemet <br />site at www.sunblz.org or call <br />850-488-9000. <br /> <br />13. PersonneVPartner Infonnatlon: Provide the full name, title, FEIN or SSN (if an FEIN is not required for your 'ousiness entity, the <br />SSN of the owner Is required), and address and telephone number of each corporate officer, owner, general partner, stockholder <br />and/or director with a controlling Interest. Make copies of this page if additional space is needed. <br /> <br />Name <br /> <br />Street address <br />CIty/State/ZIP or <br />Foreign Coun' IPostal Code <br /> <br />SSN or FEIN <br /> <br />TItle <br /> <br /> <br />o 3t.f- tJ~,~s;- <br /> <br />Ol-r' /o~U-.JIa,d.w <br />6/uJ r'L 3?f71c'2- <br />PO!3DJt. L7JL/? _ <br />CluJ R- 337/2- <br /> <br />bllt:73-31- QeYI <br /> <br />Telephone number <br /> <br />(Z~L) ~?7?:- '] ~rt' <br />x. IB.S'" <br /> <br />(]}J.) ~?'"'- 2y{d <br /> <br /> <br />(---)-------- <br /> <br />(___L___-____ <br />