Initial/Annual List and State Business License

Contact Information

Name

First Last

Email*

Enter Email Confirm Email

Phone*

NAME OF LIMITED-LIABILITY COMPANY

Entity Number

Filing period (to)

Filing period (from)

Return to:

Return one file stamped copy. (If filing not accompanied by order instructions, file stamped copy will be sent to registered agent.)

CHECK ONLY IF APPLICABLE AND ENTER EXEMPTION CODE IN BOX BELOW

Pursuant to NRS Chapter 76, this entity is exempt from the business license fee.

Exemption code:

001 - Governmental Entity - 006 - NRS 680B.020 Insurance Co.

MANAGER OR MANAGING MEMBER

Name	Address	City	State	Zip Code

Declaration of Eligibility for State Business License Exemption

Entity Name:

NV Business I.D. Number:

Choose one

Governmental Entity This entity is an incorporated or unincorporated agency or instrumentality of the United States government or any state government; a corporation wholly owned by the United States government; or county, city, district, or other political subdivision of a state.
501(c) Nonprofit Entity This entity is qualified as a 501(c) Nonprofit Entity pursuant to Title 26 U.S.C. Section 501(c). Please provide the Internal Revenue Service (IRS) issued Federal Employer Identification Number (FEIN)

Federal Employer Identification Number (FEIN)

NRS 680B.020 Insurance Company Are the activities of this entity regulated through a license or certificate of authority granted by the Division of Insurance pursuant to NRS Title 57?

Yes
No

If yes, provide license or certificate of authority number

Customer Order Instructions

Name of Entity:

Return to Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Name:

Phone

Return Delivery:

Email to:
Fax to:
Hold for Pick Up
Mail to Address Above
FedEx: Acct #
Other

Email

Fax

FedEx: Acct #

Other

please explain

Order Description: (include items being ordered and fee breakdown)*

Application Fee

Price:

Please select an additional service that you wish to have processed

Priority Request / Rush Processing + $75

Total

$0.00

Consent

I agree

I CERTIFY THAT THE RECITATIONS CONCERNING THE VESSEL: NAME, TONNAGE, DIMENSIONS, PROPULSION, OWNERSHIP, HAILING PORT, RESTRICTIONS, ENTITLEMENTS, REMARKS AND ENDORSEMENTS CONTAINED IN THE CERTIFICATE OF DOCUMENTATION REMAIN ABSOLUTELY THE SAME.

NAME:*

Type your full name to sign this secure webform

Signature*

CAPACITY OF PERSON SIGNING (E.G., AGENT, TRUSTEE, GENERAL PARTNER, CORPORATE OFFICER, MEMBER)

Authorization*

I agree

I agree to pay the above total amount according to the card issuer agreement and hereby authorize the charge for the total amount above for the processing of selected applications. I understand that my application will be processed in the order in which it is received by Corporation Center, a private fee-for-service company, not owned or operated by any governmental agency. I understand that application and processing fees are non-refundable as per Corporation Center’s no refund policy.

Credit Card

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