UCC Information Request Form
Company Information
Company's Legal Name
Doing business as (DBA), If different from Legal Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Business Start Date
-
Month
-
Day
Year
Date
# of Employees
Annual Sales
Type of Entity
Corporation
Government
LLC/Limited Liability Partnership
General Partnership
Sole Proprietorship
Other
Principals/Ownership
Includes Officers, Partners, Directors, or Proprietor
Ownership 1
*
Parent Company
Company's Legal Name
Doing business as (DBA), If different from Legal Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Public Filings
Has the Applicant, or any principals involved in the company, ever filed for protection under bankruptcy laws?
Yes
No
Date
-
Month
-
Day
Year
Date
Signature
Submit
Submit
Should be Empty: