INFORMATION REQUIRED FOR INDEMNITY AGREEMENT
FULL NAME OF CORPORATION: _____________________________________________
ADDRESS:
________________________________________________________
TAX ID NO.: ________________________
PRESIDENT: ________________________
CORP. SECRETARY:
________________________
LEGAL NAME
OF OWNER 1: _____________________________________________
% OWNED: ________________________
SOCIAL
SECURITY #: ________________________
SPOUSE’S
FULL NAME: ________________________________________________________
SOCIAL
SECURITY #: ________________________
PERSONAL
ADDRESS:
________________________________________________________
LEGAL NAME
OF OWNER 2: _____________________________________________
% OWNED: ________________________
SOCIAL
SECURITY #: ________________________
SPOUSE’S
FULL NAME: ________________________________________________________
SOCIAL
SECURITY #: ________________________
PERSONAL
ADDRESS:
________________________________________________________
LEGAL NAME
OF OWNER 3: _____________________________________________
% OWNED: ________________________
SOCIAL
SECURITY #: ________________________
SPOUSE’S
FULL NAME: ________________________________________________________
SOCIAL
SECURITY #: ________________________
PERSONAL
ADDRESS:
________________________________________________________
**IF LLC, PLEASE INCLUDE ARTICLES
OF ORGANIZATION AND OPERATING AGREEMENT.