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2. Business Name*
3. Account Number
   (if you have this information, please enter it to better assist us in finding your account)
5. State Contractors License Number*
6. Reactivation Effective Date*
   Reactivation Effective Date
8. Job Location*
9. Estimated Start and End Date*
   Estimated Start and End Date Start Date

   —

   Estimated Start and End Date End Date
13. Tell Us What You Need
15. Will you be reactivating long-term (more than 6 months)?*

    1. Yes
    2. No
17. Are you reactivating for a one time job?*

    1. Yes
    2. No
18. Report Gross Revenue*
    We will use this amount to calculate your MILL taxes.
20. Name*
21. Title*
22. Email Address*
23. Contact Phone Number*
Leave This Blank:


25. 1. Receive an email copy of this form.
26. Email address

    This field is not part of the form submission.

27. Submit

* indicates a required field