WUSB Business Underwriting Form

Business and Contact Information

Primary Contact: First and Last Name

Primary Contact: Title (Manager, Director, Owner, etc.)

Business/Entity Name:

Email Address
Where primary contact or business can best be reached.

Phone Number (with Area Code)
Where primary contact or business can best be reached.

Mailing Address/Physical Location (Street, City, Town, State, Zip Code)
Example: PO Box XXXX, Stony Brook, NY 11790

Website/Social Media Links (if available)

Please indicate the nature of your entity
Check all that apply.

Please feel free to use the space below to share any additional comments.