Form 635_0092 - Electronic Services Application And Agreement - 2011
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1
2MATT SCHULTZ
Electronic Services
Secretary of State
Application and
State of Iowa
Agreement
The below named applicant does hereby agree to the terms and conditions on
FOR OFFICE USE ONLY:
the reverse side of this application regarding the electronic services of documents
with the Iowa Secretary of State’s Office.
Date:
Account #:
PIN:
Provide all of the following information:
Approved:
This electronic services agreement is associated with the following account:
Account Name: _______________________________________________________________________________________
(Applicant) List the account name exactly as request on the Charge Account Application Form
If this is a pre-existing account, list the account number for the above account: (if known)
Account Number: _______________________________
List the name, address, phone number and e-mail address of the individual who will act as the E-services coordinator for the applicant.
________________________________________________________________________________________________________________
Name of E-service Coordinator
________________________________________________________________________________________________________________
Mailing Address
City
State
ZIP
__________________________________________________
__________________________________________________
Telephone Number
E-mail Address
List a code word which should be known only to the E-services coordinator and our office. This code word is
confidential and used for identifying the coordinator when he or she calls for assistance with PIN number.
Code Word: ________________________________________________________
If this account is to be used for filing UCC documents, list the name and address as you would like it to appear on the UCC docu-
ments as the secured or authorizing party. Note: This will enable you (at your discretion) to fill out relevant portions of the UCC
form without having to type it out each time you submit a filing.
________________________________________________________________________________________________________________
Name
________________________________________________________________________________________________________________
Mailing Address
City
State
ZIP
________________________________________ ________________________________
________________
Signature of Individual Authorizing This Agreement on Behalf of the Account Holder
Title
Date Signed
________________________________________
Print Name of Authorizing Individual
Fax to: (515) 281-4682
Review Terms and Conditions on Reverse Side
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