Finance Department 310 W. Elm St. P O Box 3006 Lodi, CA 95241-1910 Phone: 209-333-6717 fax: 209-333-6795

DBA (Doing Business As)		Fed TaxID/SSN
Owner/Corp Name		Contr Lic#
Ownership Type	Sole Proprietor Partnership Limited Liability Partnership Corporation Limited Liability Corp	Sellers Permit #
Bus Description		Phone #
Mailing Address
City, State, Zip
Attention:
Business Address	(if different then mailing address)
City, State, Zip