Information provided on this form must be certified as correct by a duly authorized Officer, Consultant or Attorney of the business entity that will be named as the execution party in the Agreement (the “Contracting Party”).
Form Submitted by:




By submitting this form, I as the requestor for the Contracting Party, do hereby certify that the foregoing information is correct. 


Contracting Party

Legal Entity Name above represents the contracting party to be legally bound by submission of this form. Include d/b/a if appropriate.

(Enter 'None' if no affiliates.)


ACNA (aka IAC Code) is a three-character alphabetic code.
Separate multiple entries with a comma.


Corporation Limited Liability Company Limited Partnership or Other


Contracting Party’s Legal Notice Contact:






Physical Address Required - P.O. Box Unacceptable



Contracting Party's Duly Authorized Officer with Execution Authority to Bind the Contracting Party:



Contracting Party's Representative Authorized to Receive the Executable Document:









Contracting Party's Individual/Department to Receive Legal Notice Regarding Tax Matters:









Contracting Party's Authorized Individual/Department to Receive Usage Data:









Contracting Party's Individual/Department to Receive Legal Notice Regarding Charges & Payments (Billing):










State Certification Information
AL - Alabama







Corporation, Limited Liability Company, Limited Partnership, or Other

AZ - Arizona







Corporation, Limited Liability Company, Limited Partnership, or Other

CA - California







Corporation, Limited Liability Company, Limited Partnership, or Other

CT - Connecticut







Corporation, Limited Liability Company, Limited Partnership, or Other

FL - Florida







Corporation, Limited Liability Company, Limited Partnership, or Other

GA - Georgia







Corporation, Limited Liability Company, Limited Partnership, or Other

IA - Iowa







Corporation, Limited Liability Company, Limited Partnership, or Other

IL - Illinois







Corporation, Limited Liability Company, Limited Partnership, or Other

IN - Indiana







Corporation, Limited Liability Company, Limited Partnership, or Other

MI - Michigan







Corporation, Limited Liability Company, Limited Partnership, or Other

MN - Minnesota







Corporation, Limited Liability Company, Limited Partnership, or Other

MS - Mississippi







Corporation, Limited Liability Company, Limited Partnership, or Other

NC - North Carolina







Corporation, Limited Liability Company, Limited Partnership, or Other

NE - Nebraska







Corporation, Limited Liability Company, Limited Partnership, or Other

NM - New Mexico







Corporation, Limited Liability Company, Limited Partnership, or Other

NV - Nevada







Corporation, Limited Liability Company, Limited Partnership, or Other

NY - New York







Corporation, Limited Liability Company, Limited Partnership, or Other

OH - Ohio







Corporation, Limited Liability Company, Limited Partnership, or Other

PA - Pennsylvania







Corporation, Limited Liability Company, Limited Partnership, or Other

SC - South Carolina







Corporation, Limited Liability Company, Limited Partnership, or Other

TN - Tennessee







Corporation, Limited Liability Company, Limited Partnership, or Other

TX - Texas







Corporation, Limited Liability Company, Limited Partnership, or Other

UT - Utah







Corporation, Limited Liability Company, Limited Partnership, or Other

WI - Wisconsin







Corporation, Limited Liability Company, Limited Partnership, or Other

WV - West Virginia







Corporation, Limited Liability Company, Limited Partnership, or Other

As the submitter, acting on behalf of the Contracting Party, I do hereby certify that the information provided on this form is correct.  I understand that by submitting this form I am providing my electronic signature.