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ATUMIZE (Ins. Add-ons)
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Owner/Officers #2
All persons who directly or indirectly own 25% of greater equity interest must be added, and if applicable, all persons with significant responsibility to control, manage or direct the business (Controller).
Name
*
First
Last
Title
*
Home Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Telephone
*
Drivers Licence Number
*
Social Security Number
*
Date of Birth
*
MM slash DD slash YYYY
Equity/ Ownership %
*
Please enter a number from
0
to
100
.
Owner #2 Email Address
*
Required for collecting signature via Docusign.
Do you need to list additional Owners?
*
Yes
No
Owner/Officer #3
Name
*
First
Last