This
form must be printed and completed in its entirety.
FAX
this completed registration to 727-467-0918
APPRAISAL EMULATION ORDERS MAY BE INCLUDED.
Please include the street address, city,
state and zip code for each property and specify your
preferred delivery method (fax or email).
REGISTRATION TURNAROUND: It may take up to
six hours to process your initial registration and return your
USER ID. For those expecting results, our turnaround is 24
business hours.
CONTACT
INFORMATION
First Name: ______________________ Last
Name:_____________________
Company Name:______________________________________ (if
applicable)
Nature
of Business:_______________________________________________
Phone: ________________________ Fax:
____________________________
Email Address:___________________________________________________
CREDIT CARD INFORMATION
(Visa or MasterCard Only)
We
DO NOT accept
American Express, Discover or Invoiced Accounts.
Account Number:
________________________________________________
Expiration Date: _________________ (mm/yy)
Name on Account:
_______________________________________________
Billing
Address:__________________________________________________
City: ________________________ State: ______ Zip
Code: ____________
Service
Agreement
I hereby agree to
comply with the provisions of the Fair Credit Reporting Act
and to only request US Home Value reports for the sole purpose
of determining property value and/or assessing risk. I shall
hold in the strictest confidence all information received and
will abide by the terms
of use. I further agree to grant AmerUSA the right
to charge my credit card for each order I (or my authorized
persons) submit.
Signature:
__________________________________ Date:______________
Print Name: _________________________________
Cardholder
Signature: _________________________
(if different from client)
INCOMPLETE
REGISTRATIONS WILL NOT BE PROCESSED.
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