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Click the Pre-Fill button at the top of the page if the Licensee Contact Representative name and address information is the same as that for the Licensee Information on the previous page. This Licensee Contact Representative page will be pre-filled with the Licensee information.
Note: If any Licensee Contact Information exists on the page and the Pre-Fill button is selected, all existing information on the page will be deleted and over-written.
Enter the First Name, Middle Initial, Last Name, and Suffix in the appropriate boxes.
Note: Do not use punctuation marks in any of the boxes provided. For example, "John Q. Smith, Sr." should be entered as "John Q Smith Sr" on this page.
Enter the name of the contact representative's company.
If the contact representative is an individual, first and last name are required.
If the contact representative is an entity, either the Individual Name or the Attention To field is required.
Complete all fields in this section which apply. You must enter either a P.O. Box or a Street Address. You must enter the City. You must select a U.S. state or territory from the pull-down menu and then enter a valid zip code.
The Phone Number is required and must be 10 digits.
Click the Clear button at the bottom of the page to clear all information from the page.
Click Continue.
