SLA LICENSE SERIAL #:

NY STATE TAX ID #:

LICENSEE NAME:

TRADE NAME (DBA):

BUSINESS PHONE #:

(###)

###

####

BUSINESS ADDRESS:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

County

DELIVERY TIME:

Delivery Instructions

SPECIAL DELIVERY INSTRUCTIONS

APPLICANT(S) FULL NAME:

First Name

Last Name

APPLICANT(S) TITLE:

CELL PHONE/ANY OTHER CONTACT:

(###)

###

####

EMAIL ADDRESS:

BANK NAME:

BANK PHONE #:

(###)

###

####

BRANCH ADDRESS, CITY, STATE, ZIP:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

All ST-120 forms must be sent to newaccounts@lnjbrands.com.