By North Carolina Judicial Branch Required Information from Prospective Licensees Please provide the information below. Current Page 1 Page 2 Complete Requester's Name Legal Entity's Name D.B.A. (Doing Business as) Name (if any) Form of Business Form of Business - Select -CorporationLLCSole ProprietorshipOther… Enter other… Name of Chief Officer Address Line 1 Address Line 2 City State - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Code Phone Number Fax Number Email Address