Complete this form to report:
- All members of the board of directors/trustees, members of the executive committee or any other governing board of the committee; and,
- If applicant is a corporation, all officers and all shareholders that directly or indirectly own 25% or more of the voting securities of the applicant if a corporation; and,
- If applicant is a partnership or association, all partners.
IMPORTANT! The Department will investigate information provided and may deny or refuse to renew a permit if the applicant fails to provide complete and truthful information about itself and the individuals responsible for the service company’s affairs.