Name

Phone Number

Address

Fax

Primary Conatct

Primary Contact Email

Billing Contact Person

Billing Email Address

Client Billing Address

Receive Invoices via Email or USPS Receive Invoices via Email or USPS Receive Invoices via Email Receive Invoices via USPS

Ability to pay via credit card Ability to pay via credit card Yes No

Will you require a W-9 from Automated Results? Will you require a W-9 from Automated Results? Yes No

Will you require a Certificate of Insurance from Automated Results? Will you require a Certificate of Insurance from Automated Results? Yes No

Please complete the equation below to submit your answers. Thank you.