Coin Laundry Package Application
Applicant Name:
Doing Business As (DBA):
Mailing Address:
Mailing City - State - Zip
Location(s) Address(es):
Location 1 City - State - Zip
(If more than two Locations,
complete an Application for each add’l Location)
Location 2 City - State - Zip
Business Entity:
Individual
Corporation
Partnership
Other
Residential Phone:
Business Phone:
Effective Date of Current Insurance:
Cuurent Insurance Carrier:
Comments or additional information: