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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:   
*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:   
*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: 1-800-262-9898 or support@alabamainteractive.org