SOC Gift Card Attestation

SOC Gift Card Attestation
Thank you for completing the SOC request. To facilitate the processing of your application for a gift card, kindly provide the information requested in the attached document. Completion and return of this form are mandatory steps in our screening procedure.
Name*

Representative's First NameLast Name
Agency Name*
Agency Email*
example@example.com
Client's Name

First NameLast Name
Client's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please select the purpose of the gift card.*
I hereby confirm I have advised my client the provided gift card is not valid for the purchase of restricted items, including but not limited to alcohol, tobacco, firearms, or any illegal substances.*

YesNo
Agency Representative Signature*
Should be Empty: