NATIONAL INTELLIGENCE SERVICE | APPLICATION FOR SERVICES -------------------------------------------------------- Name of Firm (or DBA if Applicable)____________________________________________ Telephone Number __________________________ Physical Address (PO Box and Private Mail Box are NOT acceptable) ______________________________ ______________________________ ______________________________ Fax Number __________________________ City __________________________ State __________________________ Zip __________________________ E-Mail Address __________________________ Billing Address ,if different __________________________ __________________________ __________________________ __________________________ FEIN (or SSN if Sole Proprietorship) __________________________ Billing Contact __________________________ Telephone Number, if different __________________________ Business Type: (Choose One) Corporation ___ Partnership ___ Sole Proprietorship ___ In Business Since: __________ Number of Employees: _______ Is Business Home-Based? _______ BUSINESS IDENTITY VERIFICATION (A copy of documentation as it relates to your business.) DBA Certificate, Trade Name Certificate, Articles of Incorporation, Professional License, Fictitious Name Filing, etc. City, County, State of Issue ____________________________________ License Number? ____________________________________ On File Where? ____________________________________ Preferred Method of Payment _____ Credit Card: Automatically debit the below listed credit card for our purchases as invoiced. My signature below serves as my authorization. _____ Pre-Payment: Pre-pay accounts are available for as little as $50. I will open my account with a payment of $________________________ _____ By invoice: Please invoice us. We have supplied bank & credit references below in order to secure a line of credit with NIS Credit Card Information: _____ VISA _____ M/C _____ American Express Credit Card Number ___________________________ Exp. Date ___________________________ Name Exactly as it appears on card: ___________________________________________ Bank Name ____________________________________ Type and Account# ____________________________________ Bank Address ____________________________________ Contact Name ____________________________________ Telephone Number ____________________________________ THREE BUSINESS CREDIT REFERENCES Credit & bank references MUST be supplied Company Name ____________________________________ Contact Name ____________________________________ Account Number ____________________________________ Telephone Number ____________________________________ Address ____________________________________ City, State, Zip ____________________________________ Company Name ____________________________________ Contact Name ____________________________________ Account Number ____________________________________ Telephone Number ____________________________________ Address ____________________________________ City, State, Zip ____________________________________ Company Name ____________________________________ Contact Name ____________________________________ Account Number ____________________________________ Telephone Number ____________________________________ Address ____________________________________ City, State, Zip ____________________________________ As part of your application for services, we may be required to verify credit information, business references and a bank reference on your company. Signature ____________________________________ Title ____________________________________ Date ____________________________________