PTIN Software Account Setup Form

DATE *

WHICH SOFTWARE PACKAGE DID YOU PURCHASED?

YOUR COMPANY NAME *

FIRST NAME *

LAST NAME *

MIDDLE INITIAL *

Date of birth *

Mother Maiden Name *

Business Phone Number *

Logo for mobile app (EFIN partners only)

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

CELL PHONE *

Please enter a valid phone number.

EMAIL *

SECONDARY EMAIL *

OFFICE PHONE *

SSN *

Physical Address *

City *

State *

Country *

Postal Code *

Mailing Address,City, State, Zip *

Shipping Address,City, State, Zip *

Office Address,City, State, Zip *

Business EIN (if applicable- write "applied" if applying)

PTIN (write "applied" if applying)

Bank Name *

Routing Number *

Account Number *

Driver License or State ID Number *

Driver License Expiration Date *

Driver License State *

Upload Driver Licenses *

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

HEAD SHOT PHOTO *

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Doc prep fee amount: add up to $150
Transmitter fee amount: add up to $150