Entity Submission Form

Please submit your entity information below, along with your unique submission code provided by a PickUp USA representative.

Unique Submission ID

Name

First

Last

Entity Name

Type of Entity (LLC, Corp, etc.)

Entity State of Formation

Date of Entity Formation

Entity Street Address

Entity City

Entity State

Entity Zip Code

Entity Phone Number

Entity Email Address

Owner #1 Name, address, percentage ownership, title, and spouse name (only list spouse if spouse is not an owner)

If Applicable, Owner #2 Name, address, percentage ownership, title, and spouse name (only list spouse if spouse is not an owner)

If Applicable, Owner #3 Name, address, percentage ownership, title, and spouse name (only list spouse if spouse is not an owner)

If Applicable Owner #4 Name, address, percentage ownership, title, and spouse name (only list spouse if spouse is not an owner)

General Geographic Area Within Which Franchised Business Will Be Located

All details entered are accurate to the best of my knowledge.

This is not an offer to sell a franchise, nor is it a solicitation of an offer to buy a franchise. An offer is only made after delivery of a Franchise Disclosure Document to you. If you are a resident of a U.S. state or a country that regulates the offer and sale of franchises, or you are receiving this message in one of those states or countries, or you intend to operate a franchise in such a state or country, we will not offer you a franchise unless and until we have complied with applicable law.