Entries noted with must be completed in order to process the registration.

Company Information:
		First Name: Last Name: Company Name: Mailing Address:   City , Zip Code Street Address: (if different from above)   City , Zip Code Phone Number Fax Number Email General Nature of Business: Agricultural Source? Yes No Rental Business? Yes No Provider of Essential Public Service [as defined in 13. C.C.R. § 2452(a)(34)]? Yes No