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PLEASEPRINTCONFIDENTIAL INFORMATION QUESTIONNAIRE
PATIENTS LEGAL NAMELASTFIRSTPREFER TO BE CALLEDPATIENTS ADDRESSMIDATE OF BIRTHSEXHOME PHONE #STREET APT×MITCHELL PHONE #ALLSTATE ZIP/POSTAL CODE
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P L E A stands for Payment of License Excise Application.
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Businesses and individuals who need to obtain a license or pay excise taxes.
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The purpose of P L E A is to ensure compliance with licensing requirements and collect excise taxes.
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Details such as business name, address, type of license needed, and amount of excise taxes to be paid.
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