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Forms Standard
Request
Authorization |
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| Dealer Name
_____________________________________
Date ________________ |
| Address
______________________________________________________________________ |
| Contact
_________________________________________ Voice Phone
__________________ |
| Position
_________________________________________________ Fax __________________ |
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Forms Requested |
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| _____________________________________________________________________________ |
| _____________________________________________________________________________ |
| _____________________________________________________________________________ |
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Standard forms and reports are $105.00 each. Each order of five or more forms at
one time qualifies for a discount price of $85 per form. Access requirements: Reynolds- 4880, 4816,
4780,4790, 4787, 4791, 4750, 6944. |
| Purchase Order#
________________________________________
Date ______________ |
| Modem Number# __________________
Alternate Modem # ___________________________ |
| DMS IP Address / Telnet Address (if available)
: _______________________________________ |
| UserID
______________________________________ Upper Case / Lower Case (Please
Circle One) |
| Password
____________________________________ Upper Case / Lower Case (Please
Circle One) |
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By signing below, you state that;
1. You have the authority to make this request,
2. The PO# issued is valid,
3. You authorize ProQuotes to access your system for the purpose of programming the above [form(s)/report(s)],
4. You authorize ProQuotes to contact you via telephone, fax, and or email.
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| Signature
________________________________________________ Date
______________ |
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| Printed Name
________________________________________ Title ____________________ |