APPLICATION FOR SERVICE

Complete this form entirely either on or off-line, then print it and sign it.  Fax this form and all necessary documents to JALDATA / Infonet, Inc., at 1-800-257-9135.  Your application will be processed within two business days.  You will be notified by e-mail or fax after the application has been reviewed.  If you complete the form off-line please print clearly and legibly.  Thank You!

Please send copies of your Certificate of Incorporation and business and professions licenses with your application.  We will not process your application without such documentation.
Only licensed and registered professionals and businesses will be considered.

YOUR COMPANY NAME

PHYSICAL ADDRESS

MAILING ADDRESS

CITY

STATE

ZIP CODE

PHONE

E-MAIL

FAX

COMPANY TYPE; CORPORATION, SOLE PROPRIETORSHIP, ETC.

STATE AND DATE OF INCORPORATION OR DATE OF LICENSING

PLEASE IDENTIFY THE CORPORATE OFFICER OR OWNER RESPONSIBLE FOR MATTERS CONCERNING ACCOUNTS PAYABLE.

NAME

TITLE

HOME PHONE

DOB

SSN

PHYSICAL RESIDENTIAL ADDRESS

CITY

STATE

ZIP CODE

By my signature I certify that I have read, understand and agree to the Terms & Conditions defined herein and I wish to secure an agreement and establish an account for service between my company and JALDATA / Infonet, Inc.  I declare under the penalties of perjury that I am duly authorized as an officer, owner or other authorized person acting on behalf of the company described in this Application and I declare that all of the information provided on this application form is true and correct.

PRINTED NAME

PRINTED TITLE

SIGNATURE

DATE SIGNED

The information provided on your application is retained confidentially by JALDATA / Infonet, Inc.  This information will not be sold or disclosed to any other parties except in such case where collection of an unpaid debt to JALDATA / Infonet, Inc., warrants the release of information for such collection action.