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Tax Professional Liability Basic Information

Legal Name of Firm*

Year Established*

Your "trade name" or "doing business as" name*

Effective date requested*

Your address*

City*

State*

Zip*

Mailing Address (if different)

Mailing City

Mailing State

Mailing Zip Code

Your primary contact name*

Telephone Number*

Your website address

Email Address*

Your annual gross revenues*

Less than $100,000More than $100,000

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