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License Roster
Applicant Information
Please provide the basic company information, physical and mailing address below. Bold fields or fields marked with (
*
) are required.
Basic Information
*
Legal Business Name:
*
Physical Address Line 1:
Physical Address Line 2:
*
City:
*
State:
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
*
Zip Code:
(ex: xxxxx or xxxxx-xxxx)
Mailing Information
Mailing Same As Above?:
Yes
No
*
Mailing Address Line 1:
Mailing Address Line 2:
*
City:
*
State:
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
*
Zip Code:
(ex: xxxxx or xxxxx-xxxx)
Contact Information
*
Phone Number:
(ex: xxx-xxx-xxxx)
Fax Number:
(ex: xxx-xxx-xxxx)
Email Address:
(ex: yourname@site.com)
Company Website:
(ex: http://www.yourSite.com)
Technical Support: 866-353-3468 or
support@alabamainteractive.org