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Online Payment and access to Establishment Application
Required fields are indicated with
Request Information
Name of Establishment
Name of Establishment is required.
Type of Establishment
Select Establishment Type
Person
Partnership
Corporation
LLC
Other
Type of Establishment is required.
First Name Owner \ Operator
First Name is required.
Last Name Owner \ Operator
Last Name is required.
Middle Name Owner \ Operator
Maiden Name Owner \ Operator
Email Owner \ Operator
Email is required.
Please enter a valid email.
The email address entered is already associated with another account. Please recover your existing account rather than creating a new one.
Cell Phone(Owner / Operator)
Cell phone is required.
Please enter at least one Business Phone for Establishment
Please enter a valid phone number (NNN) NNN-NNNN
NC LMBT License Number Owner \ Operator (If applicable)
Birth Date
Birth Date is required.
Please enter a valid birth date
SSN/FEID (last 4 digits)
SSN is required.
Please enter a 4 digit number
Name of Contact person at Establishment if different than Owner \ Operator
Title of Contact Person
Business Phone for Establishment
Business phone for Establishment is required.
Please enter at least one Business Phone for Establishment
Please enter a valid phone number (NNN) NNN-NNNN
Website of Establishment
Mailing Address
Address
Address is required.
City
City is required.
State
State is required.
Zip
Zip is required.
County
County is required.
Physical Address of Establishment
Address
Address is required.
City
City is required.
State
State is required.
Zip
Zip is required.
County
County is required.