Web Site Access Agreement Template - Middle District Of Florida - Jacksonville Division Page 3
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1
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3REQUIRED INFORMATION:
(Please print clearly or type)
COMPANY NAME:_________________________________________________________________________________________
USER NAME: _____________________________________________________________________________________________
TITLE: ___________________________________________________________________________________________________
ADDRESS: ________________________________________________________________________________________________
ADDRESS:_________________________________________________________________________________________________
CITY/STATE/ZIP: ___________________________________________________________________________________________
PHONE NUMBER: ________________________________________FAX NUMBER: _____________________________________
PRIMARY/OFFICE E-MAIL ADDRESS: _______________________________________________________________________
ARE YOU ALREADY AN NDC USER? ____________________
IF SO, FOR WHICH TRUSTEE?______________________________________________________________________________________
WHAT IS YOUR CURRENT NDC PRIMARY EMAIL ADDRESS?___________________________________________________
DATE: ______________________________________________________
By signing below I agree to the terms specified in the Web Access Agreement.
By:_______________________________________________Title:___________________________________
Authorizing Agent
RETURN APPLICATION TO:
Email to:
FAX to: 904-634-0038
Mail to: Douglas W. Neway, Chapter 13 Trustee
Attn: Pat Gribble
Attn: Pat Gribble
P.O. Box 4308
Jacksonville, FL 32201-4308
If mailing, please include a self addressed, stamped envelope to ensure the timely return of your ID and password. Thanks!
Approved by: _______________________________________________________ Date: _____________________________
Pat Gribble, Systems Manager
User ID: _____________________________________________ User Password: _________________________________
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