GENERAL INFORMATION |
Please complete all |
Company Name |
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DBA Name |
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Physical Address |
Please complete all |
Address |
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City |
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State |
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Zip |
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Mailing Address |
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Same as physical |
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Address |
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City |
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State |
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Zip |
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Contact Info |
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Contact Person |
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Title |
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Phone |
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Fax |
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E-Mail Address |
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Login Info |
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What USER NAME would you like to use?
(4 - 10 characters please) |
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What PASSWORD would you like to use?
(4 - 10 characters please) |
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Other Info |
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FEIN |
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Ownership Type |
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State of Incorporation |
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Date of Incorporation |
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Website |
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Insurance License # |
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Insurance License State |
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Insurance License Expires |
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How did you hear about us? |
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Years Business Established |
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Dun and Bradstreet # |
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Website |
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Compliance contact |
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Compliance E-Mail |
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IT Contact |
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IT E-Mail |
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BUSINESS REFERENCES |
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First |
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Name |
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Contact |
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Phone |
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Second |
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Name |
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Contact |
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Phone |
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STORAGE RECORDS |
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Same as physical |
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Address |
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City |
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State |
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Zip |
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OWNERSHIP |
Individual or each corporate officer of the business |
First officer |
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Firstname |
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Middlename |
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Lastname |
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Title |
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SSN |
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Second officer |
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Firstname |
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Middlename |
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Lastname |
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Title |
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SSN |
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BUSINESS TYPE |
Please select one |
Insurance Agency (MGA, Broker) |
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Insurance Company |
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Other (please describe) |
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INFORMATION MAY BE USED ONLY FOR THE FOLLOWING APPROVED PURPOSES:
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For use in connection with matters of motor vehicle or driver safety and theft;
motor vehicle emissions; motor vehicle product alterations, recalls, or advisories;
performance monitoring of motor vehicles, motor vehicle parts and dealers; motor
vehicle market research activities, including survey research; and removal of non-owner
records from the original owner records of motor vehicle manufacturers.
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For use in the normal course of business by a legitimate business or its agents,
employees, or contractors, but only: • To verify the accuracy of personal information
submitted by the individual to the business or its agents, employees, or contractors;
and • If such information as so submitted is not correct or is no longer correct,
to obtain the correct information, but only for the purposes of preventing fraud
by, pursuing legal remedies against, or recovering on a debt or security interest
against, the individual; provided, however the legitimate business may only be an
insured state-chartered or federally chartered credit union, an insured state or
national bank, an insured state or federal savings and loan association, or an insured
saving only.
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For use by any insurer or insurance support organization, or by a self-insured
entity, or its agents, employees, or contractors, in connection with claims investigation
activities, antifraud activities, rating or underwriting.
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For use in providing notice to the owners of towed or impounded vehicles.
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For use by an employer or its agent or insurer to obtain or verify information
relating to a party in interest who is a holder of a commercial driver's license.
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For use by any requestor, if the requestor demonstrates he or she has obtained
the written consent of the party in interest.
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For any other use specifically authorized under the laws of the state that hold
the Records, if such use is related to the operation of a motor vehicle or public
safety.
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PAYMENT INFORMATION |
Please complete all |
Full Bank Name |
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Bank Address |
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Bank Routing Number |
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Account Number |
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Check Number |
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Amount for Account Deposit |
$
minimum $200 required
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Please Choose Your Payment Option |
WATCH YOUR OWN ACCOUNT
If you choose to watch your own account, you have the following payment options:
1) Online Payment. Link: http://www.usdsoftware.com/pay_usd (Payment is credited instantly)
2) Check by Phone Payment. Call (718) 648-5300 ext. 204 (Payment is credited instantly)
3) Check by Fax Payment (Payment is credited instantly during business hours 9 AM - 5 PM, Monday-Friday)
Please note that watching your own account means that if you run out of money in your escrow account and don't submit a payment, you wont be able to run MVRs until you make a payment
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