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Online Payment and access to Establishment Application
Required fields are indicated with
Request Information
Name of Establishment
Type of Establishment
Select Establishment Type
Person
Partnership
Corporation
LLC
Other
First Name Owner \ Operator
Last Name Owner \ Operator
Middle Name Owner \ Operator
Maiden Name Owner \ Operator
Email Owner \ Operator
Cell Phone(Owner / Operator)
NC LMBT License Number Owner \ Operator (If applicable)
Birth Date
SSN/FEID (last 4 digits)
Name of Contact person at Establishment if different than Owner \ Operator
Title of Contact Person
Business Phone for Establishment
Website of Establishment
Mailing Address
Address
City
State
Zip
County
Physical Address of Establishment
Address
City
State
Zip
County