Shop Registration
Shop Information
Business DBA Name:
*
Required
Business Legal Name:
*
Required
Federal Tax ID:
*
Required
Tax ID must be 9 digits.
Address:
*
Required
City:
*
Required
State/Zip:
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Required
*
Required
Zipcode invalid, must be 5 digits
State Registration #:
(Required for NY, MA and RI)
Please enter registration number in correct format
State DMV #:
Contact Information
First/Last Name:
Title:
Business Phone:
*
Ext:
Scheduling Phone:
Use Business Phone
Business Fax:
Why?
*
Scheduling Fax:
Use Business Fax
Business Email:
Why?
*
Required
Invalid email
Scheduling Email:
Use Business Email
Invalid email
Do not Fax me assignments
Do not email me assignments
Send eMails in Plain Text Only
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Disclaimer: All important communications regarding Mitchell Cloud Glass, including carrier contract changes, assignments, and other business communications, are sent to your business fax and business e-mail. Your fax number and e-mail address are not shared with any third party (other than insurance carriers you have an agreement with). From time to time, Mitchell may use your fax number or e-mail address to alert you to program changes, upgrades, or additional Mitchell products you may be interested in. To opt out of these communications, please follow the instructions in such communications. The scheduling fax and scheduling email will receive assignments sent to you via the Mitchell Cloud Glass system. It is required that you provide this information, but you can elect not to have assignments sent to you. You must receive assignments via either fax or email.
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