[City of Bloomington, Illinois] License Contact Updates

Primary License Type:

Desired License Renewal Cycle:

Individual/Partnership/Corporation/LLC/ETC.:

Doing Business As Name (DBA):

Establishment Phone Number:

This email address below will be the main point of contact for all licensing and account questions or concerns. Renewals will be sent to this address. It is the responsibility of the business owner to ensure the email address on file is up-to-date.

To update the email address on file, please resubmit this form and the new email address to be added to the account.

Only ONE Email Address is Accepted per Establishment

Email Address for ALL COMMUNICATION:

PRIMARY CONTACT FOR ALL LICENSING INQUIRIES

Primary Contact Phone Number:

LOCAL CONTACT FOR EMERGENCY PURPOSES

Local Emergency Contact Phone Number:

CONTACT FOR ENTITY'S LEGAL AGENT

Does the Entity have a Legal Agent?

Yes

Legal Agent's Office Name:

Legal Agent's Phone Number:

Legal Agent's Email Address:

OWNERSHIP INFORMATION

Please list the Full Legal Name and Percent Owned for each person who owns or holds stock in the company. Percentages must equal 100%.

If you need more spaces, please email a full list of owners or stock holders to cityclerk@cityblm.org. Include your DBA in the Subject of the email.

Full Name *

Percent Owned *

Full Name

Percent Owned

Full Name

Percent Owned

Full Name

Percent Owned

Full Name

Percent Owned

Full Name

Percent Owned

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First Name

Last Name

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Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.