Ojcin Online Customer Information Form
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1
2OJCIN Online Customer Information
(Please Print Clearly)
Entity/Business Name: _
__
Profile group: ___________
(this is the first three letters of your User IDs)
Type of Business:
____________________________________
Date:
Tax ID (SSN for individuals)*: ___________________________________
Mailing Address: _
Phone: __
___
________________________________
Fax:
__
___
City, State, Zip _
_________
Authorized Representative Information – Required
(The Authorized Representative is the person who can legally represent and sign contracts for the business or
entity.)
Name: _
______________________
Title: _
____
Phone: __________________________________
Division: _____________________
Email:
If you wish to designate an Administrative Contact, please complete the following:
(In addition to the Authorized Representative, the Administrative Contact will have the authority to reset
passwords and add/modify/remove users from the subscriber account.)
Administrative Contact Information
Name: ___
___________
Title: ________________________
Phone:
Division: ______________________
Email:
_______
Primary Contact – please check one
(The primary contact will receive all account communication/information.)
Authorized Representative
Administrative Contact
Accounting Contact Information – for billed customers only
Name: ______________________________________
Title: ________________________
Phone: __________________________________
Division: ______________________
Email: _______________________________________
*Your Social Security Number/Tax ID number is requested for the purpose of verification of your identity and
review of your application for an OJCIN Online subscription. Provision of your Social Security Number/Tax ID is
voluntary. This information is confidential and can be used for collection purposes.
OJCIN Online Customer Information Form
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Parent category: Business