Shop Information

Shop Legal Name *

DBA Name (if different)

Owner Name *

Indiana Shop License # *

Contact Information

Primary Contact Name *

Email *

Phone *

Address Line 1 *

Address Line 2

City *

State

ZIP *

Supervisor Name *

Supervisor License # *

Years Licensed

I acknowledge that I have reviewed the Memorandum of Understanding (MOU) and understand that signing it is required to participate as a partner. *

I consent to be contacted regarding this application and acknowledge that my information will be handled according to the Privacy Policy. *