2. First Name*
3. Last Name*
5. Establishment Name*
7. Establishment Address*
9. Establishment Address Line 2 (if needed)
11. City
12. State
13. Zip
15. Email Address to Receive Updates
17. Informational Updates*

    Check this box if you would like to receive updates regarding new regulations and best practices, including COVID-19 emergency orders.

    1. Subscribe to informational updates
19. E-mail Annual License Renewal

    If you subscribe to annual license renewal by email you will not receive a hard copy of the renewal packet in the mail.

    1. Subscribe to receive your license renewal by email only
21. Notes
    Please use the above to space list additional establishments and addresses if you own/operate more than one, or to provide an additional email address.
Leave This Blank:


23. 1. Receive an email copy of this form.
24. Email address

    This field is not part of the form submission.

25. Submit

* indicates a required field