NATIONAL VEHICLE

TITLE & LICENSE SERVICE, INC.

P O Box 3456

Springfield, IL 62708

217-753-2318 · FAX 217-753-2352

www.nvtlsi.com

CLIENT INFORMATION FORM

Date: ______________

GENERAL INFORMATION

Business Legal Name___________________________________________________

Business Address______________________________________________________

City:___________________________ State:____________ Zip:_____________

Mailing/Billing Address (if different from above)____________________________

City:___________________________ State:____________ Zip:_____________

Phone Number: (______) _____________ Fax Number: (______) _______________

Company Web Page Address_____________________________________________

Business Contact: First Name ________________ Last Name __________________

Title/Position ___________________________ E-mail: ____________________

Billing Contact: First Name __________________Last Name: _________________

Title/Position ___________________________E-mail: ____________________

Overnight Service & Account Number: ____________________________________

Signature & Printed Name_______________________________________________