MMS Licensing Application Form

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This application form is designed to help us craft a licensing program which successfully meets your goals and objectives. There are no wrong answers. Please be candid and provide as much detail as you would like. Of course, this application form is a starting point; we will be pleased to have personal discussions with you to better determine which licensing profile best fits your interest and needs. All of your answers are confidential.

Last Name *

First Name and middle initial *

Street Address and house number *

City *

State/Region *

Postal Code *

Country *

Mobile phone (include country code) *

E-mail address *

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