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Ancillary Business Consultants, Inc.

dba CannaServe

8201 Peters Road

Suite 1000

Plantation, Florida 33324

Tel: 844-420-ADVICE (2384)

BUSINESS 0WNER

First Name *

Last Name *

Date of Birth *

Street Address *

Address Line 2

City *

State *

Zip Code *

Business Type of Interest *

Amount to Invest *

Phone Number *

Mobile Phone Number: *

COMPANY INFORMATION

Legal Name of Entity:

Business Inception Date:

Federal Tax ID (EIN):

State Where Business Was Formed:

Legal Entity

Corporation

LLC

Partnership

Sole Proprietership

Home Based Business:

Yes

Street Address

Address Line 2

City

State

Zip Code

Phone Number

Website:

Email Address

Full Time Employees

Part Time Employees:

Estimated Monthly Revenue:

Ownership of Business Location:

Owned

Rented

Landlord Type:

Management Company

Sole Ownership

Corporation

Other

If Owned, Property Value:

Monthly Rent:

Signature:

clear

Date:

Title:

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"CannaServe" is a registered trademark of Ancillary Business Consultants, Inc. Any unauthorized use or publication the trademark "Canaserve" is strictly prohibited.