Monthly Billing Registration Form

 Contact Information:
 First & Last Name      
 Phone Number:
   [Phone extension is optional]
 E-Mail Address:   [this is also your username]
   [You need to enter your e-mail address twice]
   [You need to enter your password twice]
 Website Address:
 Why are you using this service?
 How did you find us?

Yes, I want to receive email about new products, specials and industry news!

 Business Information:
 Company/Legal Business Name:    
   ["Doing Business As" name is optional]
 Street Address:    
 State & Zip Code:        
 Business Phone Number:
   [business phone extension is optional]
 Federal Tax ID# (EIN):
   [description]An Employer Identification Number (EIN) is also known as a Federal Tax Identification Number, and is used to identify a business entity. Generally, businesses need an EIN. You may apply for an EIN in various ways, and now you may apply online. Simply go to and then click on the “Online EIN Application” link to apply for an EIN if you do not currently have one… For sole proprietorships the social security number (SSN) can be used as an EIN.

 Mailing Address:
   My Mailing Address is the same as my Business Address above 
 Street Address:    
 State & Zip Code:        

Monthly Billing Options:
As part of our approval process, you must place at least 1 order using a credit card or mail us a check for $100
1: Credit Card
Please bill my credit card at the end of each calendar month.
2: Pay By Check - You will be invoiced with Net 30 payment terms
      I will process an order using a credit card
      I will mail you a check for $100

 Credit Card Information: We accept Master Card, Visa, American Experss and Discover credit cards. 
 Cardholder Name:
   [Enter name exactly as appears on your card]
 Card Number:
   [no spaces or hyphens]
 Expiration Date:
 Street Address:    
 State & Zip Code:        

 PayPal Payment Information: We accept PayPal, Google Checkout and the following Credit Cards: Master Card, Visa, American Experss and Discover. 
 Your Full Name:  

 Google Checkout Payment Information: We accept Google Checkout, PayPal and the following Credit Cards: Master Card, Visa, American Experss and Discover. 
 Your Full Name:  

Please mail company check to:
Screening Intelligence LLC
75 Arlington Street, Suite 500
Boston, MA 02116
Please make your check payable to: Screening Intelligence LLC
After we receive and deposit your company check, an account representative will contact you.

 Billing Information:
   My Billing Information is the same as my Contact Information 
 First & Last Name :      
 Billing E-Mail Address:  
   [You need to enter your e-mail address twice]
  Please only send monthly invoices to this email address.
 Billing Phone :
   [phone extension is optional]

*By submitting your registration information and typing the word "AGREE"
you are indicating your acceptance of our Terms of Use and have read and understand our Privacy Statement. Your submission of this form will constitute your consent to receive required administrative and legal notices electronically.
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