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BASIC BROKER AUTHORITY ORDER FORM

Enter the name of the person or officer that will be the responsible party:

Title or Role

Enter the name of your Company. If you are a "Sole Proprietor" enter your first and last name

Select the Type Company You Are:

Please enter your MAILING Address

State:

Enter Your Physical Address:

State:

Check the type of Authority you want

Payment Information

Your credit card will be debited by Fleet Management Strategies a total of the the amount stated below. FMS accepts credit or debit cards. Visa, MasterCard, Discover and American Express.

Billing State:

By submitting this application I certify that the above information is true and correct and I have reviewed and agree to the entire terms and conditions (Terms and Conditions)