Business or Individual Information:
Business or Individual's Name:
Division, Store Number, or Location(Optional):
Address:
City:
State:    Zip:
 
Primary Contact:
Phone:
Fax:
Amount of Bank Service Charge your business pays for each dishonored check: $
Number of cash registers for which you will need Notification Signs:  
Approximate number of worthless checks you receive per year:  
If several business locations are involved, please complete a separate registration form for each location.
 

Central Location Information:
Location Name:
Primary Contact:
Address:
City:
State:    Zip:
 
Phone:
Fax:

  Send the Following to the Central Address Location:
Victim Confirmation - Acknowledging receipt of worthless checks for processing.
Restitution - Restitution checks and confirmation letters.
Finalization Notice - Notices of checks returned as uncollectible, cases resolved or otherwise finalized.
Other - Miscellaneous communications.
  Specify:
      
 

Special Handling Requests: