User Agreement

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VeriRes Account Application

Please complete the following application and then press the submit button at the bottom
of the page. There will be a $25, non-refundable, fee for processing the application.

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Required Reading:
Click Here > TERMS & CONDITIONS < Click Here
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ENTER COMPANY NAME:

ENTER YOUR NAME & TITLE:

ENTER FEDERAL TAX ID or SSN:

ENTER TYPE of BUSINESS:

ENTER STREET ADDRESS:

ENTER CITY:

ENTER STATE:

ENTER ZIP CODE:

ENTER BUSINESS PHONE:

ENTER BUSINESS FAX:

ENTER EMAIL ADDRESS:

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WHAT TYPE of ACCOUNT DO YOU WISH TO ESTABLISH?

Credit Card click here >

Deposit Account click here >
($500 Minimum)

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If you will be opening a credit card account, please submit the following information:
(Your credit card number will be encrypted before transmitting.)

Name of Person on Card:

Credit Card Type: {Select
Expiration Date: Month Year {Select Both

Credit Card Number:
- -
-

(Leave last box blank if using American Express.)

PLEASE PLACE QUESTIONS and COMMENTS HERE:

Please give details or, specify any requests that you have.

ALL INFORMATION IS KEPT CONFIDENTIAL !