Please fill out and return the following questionnaire to BIS via email or fax to:

[email protected], or Fax 866-855-5999

Company Information:

Company Name:		Office Hours:
Mailing Address:
City:	State:		Zip Code:
Phone Number:		Fax Number:
Office Contact:		Email:
Filing for County (s)		Phone Number:

Banking Information:

Bank Name:
Routing Number: (Must be 9 digits)	Account Number:
Bank Name:
Routing Number: (Must be 9 digits)	Account Number:
Bank Name:
Routing Number: (Must be 9 digits)	Account Number:
Bank Name:
Routing Number: (Must be 9 digits)	Account Number:
Bank Name:
Routing Number: (Must be 9 digits)	Account Number:
Bank Name:
Routing Number: (Must be 9 digits)	Account Number:

*Attach additional sheet with the above information if needed.