CPA - Original Corporate / Partnership / LLC / LLP Permit

This application is for a:

President/Partner Name:

Resident Agent Name::
City, State Zip: , MD -

Corp./Partnership/LLC/LLP Name:
Business Address:
City, State Zip: , -
County of Business Address:
Contact Phone No.: - -
Contact Person Email Address:

Federal ID:
For Corporation/LLC/LLP Only: Name of State in which incorporated and date of Certificate of incorporation.
State: Date: --

 I have Workers Compensation Coverage   Policy/Binder No.

Issued by the  

 I am not an employer required to provide employee coverage under the Workers Compensation Law.

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