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DG & J, Incorporated

“The Court Help Company”.

NEW ACCOUNT REGISTRATION

Name:______________________________________________= _______________________  =

 

Title:_____________________________________________= _________________________

 

Company:___________________________________________= _______________________

 

Mailing Address:___________________________________= _________________________

 

City:____________________________________________, = MI  Zip:________________<= /o:p>

 

Physical Address:__________________________________= __________________________

 

City:____________________________________________, = MI  Zip:________________<= /o:p>

 

Phone:_____________________________________________= ____X__________________

 

Fax:_______________________________________________= _______________________

 

E-mail:____________________________________________= ________________________

 

Payment method:&nb= sp;  ___ monthly statement&nbs= p;   ____ per occurrence check  ___  credit= card     

 

Credit card: =    ___ Visa  &n= bsp;     ___ MasterCard     ____ American Express    ____ Discover

 

Number:__________________________________________    Expiration:_______= _____

 

Name as it appears on card:________________________= __________________________

 

Billing address of credit card:____________________= ____________________________

   &= nbsp;           &nbs= p;         = ;                 = ;                 = ;         =

Credit card signature:_____________________________= __________________________

 

 

By signing below, you agree to pay all charges to y= our account within 30 days of notice,

by the manner above selected.

 

 

Sign:______________________________________________= ________________________

 

Printed name:______________________________________= ____________________

 

date:_________________________

 

Return form by fax to (269) 721-8031.  Your account number and password will be e= -mailed to you following information verification by phone.  For security reasons, charges to your accoun= t will not be accepted without your password and account information.

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DG & J, Incorpor= ated
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