New Organization Enrollment Form

New Organization Enrollment Form

New Organization Enrollment Form
Organization / Corporate Information

Basic Organization Information
- Main Organization / Corporate Contact
  
  First NameLast NameSuffix
- Main Organization / Corporate Contact Email
  example@example.com
- Main Organization / Corporate Contact Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Organization / Corporate Legal Name
- Organization / Corporate DBA
  If applicable.
- Organization / Corporate Billing Address
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Organization / Corporate Alternate Mailing Address
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Complete "Individual Organizations / Dealerships" only if you are a multi-point dealer group or organization. Not required for singular dealers/organizations.
- Individual Organizations / Dealerships

User Information

Complete User Enrollment Sections Below
- Administrators will have full access to all transactions, across all sub-dealers/organizations.
- Administrators
- Single Dealer Users will have full access to all transactions, across a single sub-dealer/organization.
- Single Dealer Users

Payment Preferences

Choose one option below
Payment Preference

ACH Information

Complete ACH Information to generate ACH Agreement
Auto Pay Preference
Bank Name
Bank Address

Street Address

Street Address Line 2

CityState

Zip Code
Account Type

Other
Name of Account Holder
Routing Number
Account Number

ACH Information

Enter Email, Follow DocuSign Instructions at Top of Module to Sign.
Enter your name and email into the module below. When prompted, drag and drop the "Signature" widget to sign agreement.

Credit Card Authorization

Complete Credit Card Authorization Fields to Generate Credit Card Authorization Form
Auto Pay Preference
Card Type

Other
Cardholder's Name
As shown on card
Billing Zip Code

Terms and Conditions

Scroll to the bottom of the Terms & Conditions to Continue

Completed Work Preferences

Please tell us where you'd like the customer's physical plates and documents to go after processing.
Physical Registration/Title/Plate Completion Should Be Delivered To:
Pre-Paid Label Preference

Refund Preferences

Tell us how you'd like to receive overage monies collected, if any apply.
Who should refund monies be payable to?

Other

Invoice Preferences

Tell us how you'd like to receive billing for monies underpaid, if any apply.
Who should invoices be billed to?

Other

Missing Document Preferences

Tell us how you'd like to receive notification/action for documents not collected, if any apply.
Who should we reach out to if document package is not complete or errors occur?

Other
Should be Empty: