4 Enter the business mailing address. Include the physical address if different entity’s Entity Address from mailing address. 5 Enter the county where the headquarters is located. entity’s Entity Headquarters County 6 Enter the telephone number (Including Area Code) for the entity. Entity Telephone No. Part C Individual Applicant Information – 1 Enter the complete legal name. applicant’s Applicant’s Full Legal Name 2 Enter digit social security number or tax ID number. applicant’s 9 9 Digit Applicant’s ID Number 3 Enter date of birth (MM-DD-YYYY). applicant’s Birth Applicant’s Date 4 Enter complete mailing address, including physical address if different applicant’s from mailing address. Applicant’s Address 5 Enter county the applicant resides in or the county where the headquarters office is Residence or located. Headquarters 6 Enter home or business telephone number, including area code. applicant’s Applicant’s Telephone No. 7 the box that most closely corresponds to current For individual applicants’ check Marital Status marital status. Part D Other Information – 1 If the individual or entity applicant has conducted business under any other name, Other Business If not, answer answer “YES”. “NO”. Names If the other name(s) the applicant has used. “YES”, enter 2A Check the appropriate box indicating your ethnicity. Ethnicity 2B Check the appropriate box or boxes indicating your race. Race 2C Check the appropriate box indicating your gender. Gender 2D Check the appropriate box indicating your veteran status. Veteran Status
4 Entity Address Enter the entity’s business mailing address. Include the physical address if different from mailing address. 5 Entity Headquarters County Enter the county where the entity’s headquarters is located. 6 Entity Telephone No. Enter the telephone number (Including Area Code) for the entity. Part C – Individual Applicant Information 1 Applicant’s Full Legal Name Enter the applicant’s complete legal name. 2 Applicant’s 9 Digit ID Number Enter applicant’s 9 digit social security number or tax ID number. 3 Applicant’s Birth Date Enter applicant’s date of birth (MM-DD-YYYY). 4 Applicant’s Address Enter applicant’s complete mailing address, including physical address if different from mailing address. 5 Residence or Headquarters Enter county the applicant resides in or the county where the headquarters office is located. 6 Applicant’s Telephone No. Enter applicant’s home or business telephone number, including area code. 7 Marital Status For individual applicants’ check the box that most closely corresponds to current marital status. Part D – Other Information 1 Other Business Names If the individual or entity applicant has conducted business under any other name, answer “YES”. If not, answer “NO”. If “YES”, enter the other name(s) the applicant has used. 2A Ethnicity Check the appropriate box indicating your ethnicity. 2B Race Check the appropriate box or boxes indicating your race. 2C Gender Check the appropriate box indicating your gender. 2D Veteran Status Check the appropriate box indicating your veteran status.
FSA_2210_Instructions_Application_EZ_Guarantee-1.docx