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Agency Owner

Your Name(required)
Social Security Number
Date of Birth
Email(valid email required)
Home Address
Telephone Number(required)

Agency Information

Agency Name(required)
Agency ID
Shipping Address(required)
Business Phone(required)
Business Fax Number
Business Entity FEIN#
Do you already have an E-File Identification Number (EFIN)?
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If yes, my EFIN is
Name EFIN Holder
EIN/SSN for EFIN Holder

Ownership Type

LLC
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Provide the following info for all tax preparers who will be working in your agency:

Name, SSN or PTIN# & Email
Name, SSN or PTIN# & Email
Name, SSN or PTIN# & Email
Name, SSN or PTIN# & Email
Name, SSN or PTIN# & Email
Name, SSN or PTIN# & Email

Please answer the following questions:

Have you already registered as a Loan Facilitator with the NC Banking Commission?
Yes No
Have you ever been convicted of a crime?
Yes No
Have you ever been disciplined by any regulatory body?
Yes No
Have you ever prepared taxes prior to this day?
Yes No

All Yes responses must be explained in an attachment

Please upload a .doc or .pdf file

I hereby declare the foregoing statements are true and correct

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