Membership Application
Version 4.2015
Company Name: ___________________________________________ Also Doing Business as: __________________________
Contact Name: _____________________________________________ Title: _________________________________________
Company Main Phone #: _____________________________________ Web Page Address:_______________________________
Physical Address: Billing Address:
Street Street
City State County Zip City State County Zip
**** Nature of Business: _______________________________________ Date Established: ______________________________
**** Intended use of Product(s): Pre-Employment Tenant Franchisee
Is the company exempt from sales tax?
If "Yes
"
provide the appropriate resale or exemption certificate(s). Yes No
Is the applicant engaged in the underwriting of insurance? Yes No
Is the company licensed or providing service as an attorney or detective/investigative agency?
If "Yes" indicate which: ____________________________________________________________ Yes No
Does the company intend to resell or release information from the consumer credit report to a third party? Yes No
Does the company provide credit repair or credit services for a fee? Yes No
Will the company, or does the company have an Internet Web site address?
If "Yes" please list site address ______________________________________________________ Yes No
Is the business:
A publicly held company under the regulatory authority of the US Securities and Exchange Commission? Yes No
Listed in the Financial Industry Regulatory Authority’s (FINRA) publication OTC Bulletin Board (OCTBB)? Yes No
Subject to the regulatory authority of any agency listed in Section 621(b) of the FCRA, 15 U.S.C § 1681s(b)? Yes No
A licensed insurance company? Yes No
Approved by the Internal Revenue Service as a tax-exempt organization pursuant to Section 501(c)(3) of
the Internal Revenue Code 26 U.S.C. § 501(c)(3)? Yes No
Certified by the Small Business Administration for participation in an SBA-administered program? Yes No
Certified by the by the Department of Transportation for participation in the Department of Transportation’s
Disadvantaged Business Enterprise Program? Yes No
A Federal or State Agency? Yes No
A franchise recreational vehicle dealership (auto and motorcycle dealerships excluded) that can be
verified as such through the direct manufacturer’s website? Yes No
A franchise auto dealership that can be verified as such through the direct manufacturer’s website? Yes No
A mortgage broker and works from a residential site with proper verification? Yes No
