Add Additional Contact

Please enter all information below


(XXX) XXX-XXXX

(XXX) XXX-XXXX

For Security Purposes

Please enter all information below. You will not be allowed to continue until all required information has been entered. If you have any questions on any of the information in a section, you may click the section header, which will pop up a new window with more information about the fields in that section.

Agency Contact

This is information about the person completing this package - this person MUST be authorized to sign legal documents on behalf of the the agency/company.


Acceptable: Owner, Agent, Principle, etc.
NOT Acceptable: Mr., Mrs., etc

For Security Purposes

We are capturing the NPN to electronically verify the agent license and to improve the setup process for our customers

Additional Contacts

Each individual who requests reports from LexisNexis must apply for a User ID. If you know the information for additional individuals who will order reports,
please click the "Add Additional Contact" button below and enter the required information.

Contact Information
Please click the "Add Additional Contact" button below.
Agency Information

A completed application is required for each physical location.

(XXX) XXX-XXXX

  

(XXX) XXX-XXXX

  

P.O. Box not accepted

XXXXX or XXXXX-XXXX

  to  

Only fill out one IP Address if you do not have a range assigned to you.

XXX-XX-XXXX

XX-XXXXXXX

You must add an IP address for each physical location (i.e., working from home, another alternate location, etc.)

††SSN OR Federal Tax ID is required to process your application.

Billing Address

A billing address is only needed if it is different than your mailing address.

  
Witness Information

In order for the signature of the witness to be electronically signed and the forms completed, you must type the first and last name, telephone number, fax number, title and e-mail address of the witness in the appropriate fields. The witness must be someone other than yourself. Your witness should be present when you enter his/her name so the witness will be able to attest to the fact that you electronically signed these forms.

Acceptable: Owner, Agent, Principle, etc.
NOT Acceptable: Mr., Mrs., etc

(XXX) XXX-XXXX

(XXX) XXX-XXXX

Sponsor Information

A minimum of one sponsor is required. You may reference up to six total sponsors to assist us with the proper setup of your account. If you have an Agency ID code, please enter it in the field below. If you are unsure or do not have one, please enter "None". Click the "Add Sponsor" button if you need to enter more sponsor names. It is your responsibility to contact any and all sponsoring companies and request that they submit the appropriate authorization on your behalf. Failure to do so will delay the account setup process.

Sponsoring CompanyAgency ID Code
If problems arise and you are not taken to the next step, please contact Customer Support at 1.800.456.6432.