PTIN SOFTWARE ENROLLMENT

Basic Information

First Name *

Last Name *

Company Name *

Phone *

Email *

Mailing Address

Address *

State *

City *

Postal code *

Country *

PTIN Holder Information

Please verify all information is 100% accurate prior to submitting

PTIN Number *

PTIN Owner's First Name *

PTIN Owner's Last Name *

PTIN Issued State *

PTIN Issued Street Address *

PTIN Issued City *

PTIN Issued Postal / Zip Code *

PTIN Owner Cell Phone Number *

PTIN Owner Email *

PTIN Owner's Date Of Birth *

Create Software Username Below

DTS Username *

PTIN Owner State Photo ID *

PTIN Owner State Photo ID (Back) *

Financial Information

Name of Financial Institution *

Type Of Account

Name On The Account *

Routing Number *

Account Number *

Primary Use Of Account *