COMPANY INFORMATION

{ binding firstError.message }
{ binding firstError.message }
Owner Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

Company Email Address

{ binding firstError.message }

Company Phone Number

{binding IsCompanyPhoneACellPhone_Label, source = {{ $context.parentContext.dataItem }} } {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

For App Status Notifications

Cell Phone number is required for the following notifications:

  • Confirmation of filing
  • Status updates
  • Optional Random Test Selection (if opted in)
  • Query reminders

 

 

Company Physical Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Provide Mailing Address below {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Is the company address the same as mailing address? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

 

 

OPERATION TYPE: 

ARE YOU OWNER-OPERATOR OR EMPLOYER?

Self/Employed or Employer {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
  • Owner-Operators are those employers who employ themselves as CDL drivers, typically a single-driver operation.
  • Employer would be the company that employs drivers to conduct transportation on behalf of that company. 

 

 

FMCSA PORTAL INFORMATION 

Do you have your account login information to the FMCSA Portal? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
FMCSA Portal Set Up Choice {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }

Provide FMCSA Credentials Below

{ binding firstError.message }
{ binding firstError.message }

If you do not know your PIN number  or if your PIN number is incorrect, please visit https://safer.fmcsa.dot.gov/AutoPin/index.xhtml

{ binding firstError.message }

FMCSA PORTAL

 

To set up your FMCSA Portal, please select 3 security questions below and provide answers.

{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
 

 

YOUR EMAIL ADDRESS  WILL BE USED AS YOUR USER ID. 
PLEASE TYPE IN YOUR PASSWORD

 
NOTE THAT PASSWORDS CANNOT CONTAIN PHRASES USED IN THE USERNAME OR EMAIL.
Password must include combination of all of the following :

- One Capital Letter
- At Least 12 Characters Long
- Numbers
- Lower Case Letters
- Must Include a Special Character
(example: !@#$%)

{ binding firstError.message }
{ binding firstError.message }

Password must be at least 12 characters long and cannot include any phrases used in the username. 

{ binding firstError.message }

 

 

{ binding firstError.message }

example: 1L34UX3P

Please note that the DOT PIN number is 8 characters long and it comes in the following format: number-letter-number-number-letter-letter-number-letter. 

Example: 1L34UX3P

{ binding firstError.message }

IMPORTANT:
UPON COMPLETING SETTING UP YOUR FMCSA PORTAL, PLEASE EMAIL ADMIN@CLEARINGHOUSEPORTAL.US THE FMCSA CREDENTIALS, IN ORDER TO FINALIZE LINKING (CONNECTING) YOUR FMCSA ACCOUNT TO YOUR CLEARINGHOUSE ACCOUNT.

 

 

QUERIES:

QUERIES MUST BE CONDUCTED PRIOR TO EMPLOYMENT AS WELL AS EVERY YEAR PRIOR TO HIRING 'ANNIVERSARY'.

QUERIES APPLY TO EMPLOYER HIRING CDL DRIVERS AND OWNER-OPERATORS.

 

 

{ binding firstError.message }

 

 

DRIVER(S) INFORMATION

IF YOU CURRENTLY DON'T EMPLOY DRIVERS OR AREN'T DUE FOR A QUERY CLICK "X" NEXT TO DRIVER 1. 

Driver {binding ItemNumber}

Driver's Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

To ensure prompt request turn-around, please check your CDL number for accuracy.

 


The driver's that your company employs must have an active Clearinghouse Driver's Account in order to consent to be queried. 


Below you have an option to add Driver's Clearinghouse Account 

Does this Driver require the Driver's Clearinghouse Account? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
Driver's Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }

 

 --- TO ADD MORE DRIVERS SELECT  Add Driver BELOW

{ binding firstError.message }

OWNER-OPERATOR QUERY INFORMATION

 

 

{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

To ensure prompt request turn-around, please check your CDL number for accuracy.

 

 

 

As Owner-Operator you are required to conduct a query and CONSENT to query from the Driver's Clearinghouse Account.

Select 'Yes' to set up the Driver's Account for a fee of $60 dollars.

Otherwise you will need to set up this account on your own.

Set Up Driver's Clearinghouse Account {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

 

 

 

RANDOM DRUG & ALCOHOL TESTING PROGRAM REQUIREMENT

Important: All CDL (Class A) drivers must enroll in Random Drug and Alcohol Administration Program per FMCSA (FMCSR 382).


Federal Applications Processor Hoffenmer (processor of this application) is approved Consortium/Third-Party Administrator (C/TPA) offering Random Drug and Alcohol Program membership.

For more information please call the Random Enrollment Hotline:  (240) 544-0909

 

 

RANDOM DRUG & ALCOHOL PROGRAM FOR EMPLOYERS

Are you and your drivers currently enrolled in Random Drug and Alcohol Testing Program? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

(Consortium Program Name)

Enroll your Driver's in Random Drug and Alcohol Program? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }

Select YES to enroll drivers in Random Drug and Alcohol Program

{ binding firstError.message }

RANDOM DRUG & ALCOHOL PROGRAM (OWNER - OPERATORS )

Are you currently enrolled in a FMCSA Random Drug & Alcohol Testing Program? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

(Consortium Program Name)

Enroll in Random Drug and Alcohol Program? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }

Select YES to enroll drivers in Random Drug and Alcohol Program

You will be automatically enrolled under FAP Hoffenmer Random Drug & Alcohol Program - a requirement for all Owner-Operators of vehicles above 26,000 GVWR.

 

Pre-Employment Drug & Alcohol Test:

Owner/Operators are required to adhere to the Pre-Employment regulations for Drug & Alcohol Test. 

{ binding firstError.message }
{ binding firstError.message }

Zip Code nearest to location where driver will be scheduled for a test

{ binding firstError.message }

RANDOM DRUG & ALCOHOL PROGRAM:

Important: As a self-employed driver (owner-operator, or O/O), you must use one or more consortia/third party administrators (C/TPAs) to manage the drug and alcohol testing program.

O/O must identify their C/TPA(s) in the Clearinghouse which automatically designates them and enables C/TPA to act on their behalf in the Clearinghouse, as required by CFR 382.705(b)(6).

By enrolling in the Random Drug & Alcohol Testing Program your company will use 'Hoffenmer' as your C/TPA (third-party administrator) to manage your Clearinghouse Portal, in fulfillment of CFR 382.705(b)(6).

{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

 

 

SIGNATURE & AGREEMENT


 

{ binding firstError.message }

Expedited requests are completed the following business day. 

Otherwise, process of Clearinghouse registration is offered on a first-come first-served basis.

 

 

 

 

CLEARINGHOUSE REGISTRATION PROGRAM AGREEMENT CLEARINGHOUSE REGISTRATION TERMS AND CONDITIONS - PLEASE CLICK THE LINK TO REVIEW THE TERMS AND CONDITIONS.

I HAVE READ AND AGREE TO CLEARINGHOUSE REGISTRATION TERMS AND CONDITIONS {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Name of Person Completing This Application: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Job Title  {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

Use your computer mouse to sign, or open the application on touch-screen device to sign with your finger.

{ binding firstError.message }
Today's Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

 

 

{ binding firstError.message }

 

 

{ binding firstError.message }

FOR INTERNAL USE ONLY. LEAVE BLANK.

{~ Payment_Block_Label}

{binding Group}
{binding Name} - {binding Description}{binding displayValue}
{{ Cognito.resources['payment-subtotal'] + ":" }}{binding displayValue}
{binding Name}:{binding displayValue}---
{{ Cognito.resources['payment-amount-due'] + ":" }} {binding displayValue}

{{ Cognito.resources['order-transaction-details-header'] }}

{{ Cognito.resources['order-number-label'] }}: {binding displayValue}
{{ Cognito.resources['order-date-label'] }}: {binding displayValue}
{{ Cognito.resources['order-method-label'] }}: {binding MethodReference}
{binding Group}
{binding Name} - {binding Description}{binding displayValue}
{{ Cognito.resources['payment-subtotal'] + ":" }}{binding displayValue}
{binding Name}:{binding displayValue}
{{ Cognito.resources['order-total-label'] }}: {binding displayValue}
{{ Cognito.resources['order-amount-paid'] }}:({binding displayValue})
{{ Cognito.resources['order-balance-due-label'] }}:{binding displayValue}

{{ Cognito.resources['order-transaction-details-header'] }}

{{ Cognito.resources['order-number-label'] }}: {binding displayValue}
{{ Cognito.resources['order-date-label'] }}: {binding displayValue}
{{ Cognito.resources['order-method-label'] }}: {binding MethodReference}
{binding Group}
{binding Name} - {binding Description}{binding displayValue}
{{ Cognito.resources['payment-subtotal'] + ":" }}{binding displayValue}
{binding Name}:{binding displayValue}
{{ Cognito.resources['order-total-label'] }}: {binding displayValue}
{{ Cognito.resources['order-amount-paid'] }}:({binding displayValue})
{{ Cognito.resources['order-balance-due-label'] }}:{binding displayValue}

 

 

COMPANY INFORMATION

Company Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
U.S. DOT Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Owner Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Company Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{binding IsCompanyPhoneACellPhone_Label, source = {{ $context.parentContext.dataItem }} } {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Cell Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

Cell Phone number is required for the following notifications:

  • Confirmation of filing
  • Status updates
  • Optional Random Test Selection (if opted in)
  • Query reminders

 

 

Company Physical Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Provide Mailing Address below {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Is the company address the same as mailing address? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }

 

 

OPERATION TYPE: 

ARE YOU OWNER-OPERATOR OR EMPLOYER?

Self/Employed or Employer {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
  • Owner-Operators are those employers who employ themselves as CDL drivers, typically a single-driver operation.
  • Employer would be the company that employs drivers to conduct transportation on behalf of that company. 

 

 

FMCSA PORTAL INFORMATION 

Do you have your account login information to the FMCSA Portal? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
FMCSA Portal Set Up Choice {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

Provide FMCSA Credentials Below

Enter FMCSA Portal Username ID: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Enter FMCSA Portal Password: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

If you do not know your PIN number  or if your PIN number is incorrect, please visit https://safer.fmcsa.dot.gov/AutoPin/index.xhtml

{ binding firstError.message }

FMCSA PORTAL

 

To set up your FMCSA Portal, please select 3 security questions below and provide answers.

Question 1: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Answer 1: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Question 2: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Answer 2: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Question 3: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Answer 3: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
 

 

YOUR EMAIL ADDRESS  WILL BE USED AS YOUR USER ID. 
PLEASE TYPE IN YOUR PASSWORD

 
NOTE THAT PASSWORDS CANNOT CONTAIN PHRASES USED IN THE USERNAME OR EMAIL.
Password must include combination of all of the following :

- One Capital Letter
- At Least 12 Characters Long
- Numbers
- Lower Case Letters
- Must Include a Special Character
(example: !@#$%)

USER ID:  {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
PASSWORD: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Re-type password {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

 

 

US DOT PIN Number: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

Please note that the DOT PIN number is 8 characters long and it comes in the following format: number-letter-number-number-letter-letter-number-letter. 

Example: 1L34UX3P

{ binding firstError.message }

IMPORTANT:
UPON COMPLETING SETTING UP YOUR FMCSA PORTAL, PLEASE EMAIL ADMIN@CLEARINGHOUSEPORTAL.US THE FMCSA CREDENTIALS, IN ORDER TO FINALIZE LINKING (CONNECTING) YOUR FMCSA ACCOUNT TO YOUR CLEARINGHOUSE ACCOUNT.

 

 

QUERIES:

QUERIES MUST BE CONDUCTED PRIOR TO EMPLOYMENT AS WELL AS EVERY YEAR PRIOR TO HIRING 'ANNIVERSARY'.

QUERIES APPLY TO EMPLOYER HIRING CDL DRIVERS AND OWNER-OPERATORS.

 

 

ENTER NUMBER OF DRIVERS TO QUERY {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

 

 

DRIVER(S) INFORMATION

Driver {binding ItemNumber}

Driver's Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Select Driver License Country {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Select Driver License State {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Date of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Driver License Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Re-enter Driver License Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

 


The driver's that your company employs must have an active Clearinghouse Driver's Account in order to consent to be queried. 


Below you have an option to add Driver's Clearinghouse Account 

Does this Driver require the Driver's Clearinghouse Account? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Driver's Email Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Driver's Cell Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Driver's Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

 

 --- TO ADD MORE DRIVERS SELECT  Add Driver BELOW

{ binding firstError.message }

OWNER-OPERATOR QUERY INFORMATION

 

 

Select Driver License Country {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Select Driver License State {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Date of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Driver License Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Re-enter Driver License Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

 

 

 

As Owner-Operator you are required to conduct a query and CONSENT to query from the Driver's Clearinghouse Account.

Select 'Yes' to set up the Driver's Account for a fee of $60 dollars.

Otherwise you will need to set up this account on your own.

Set Up Driver's Clearinghouse Account {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }

 

 

 

RANDOM DRUG & ALCOHOL TESTING PROGRAM REQUIREMENT


Federal Applications Processor Hoffenmer (processor of this application) is approved Consortium/Third-Party Administrator (C/TPA) offering Random Drug and Alcohol Program membership.

For more information please call the Random Enrollment Hotline:  (240) 544-0909

 

 

RANDOM DRUG & ALCOHOL PROGRAM FOR EMPLOYERS

Are you and your drivers currently enrolled in Random Drug and Alcohol Testing Program? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Enter the name of Random Program Administrator you're enrolled with: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Enroll your Driver's in Random Drug and Alcohol Program? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }

RANDOM DRUG & ALCOHOL PROGRAM (OWNER - OPERATORS )

Are you currently enrolled in a FMCSA Random Drug & Alcohol Testing Program? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Enter the name of Random Program Administrator you're enrolled with: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Enroll in Random Drug and Alcohol Program? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

You will be automatically enrolled under FAP Hoffenmer Random Drug & Alcohol Program - a requirement for all Owner-Operators of vehicles above 26,000 GVWR.

 

Pre-Employment Drug & Alcohol Test:

Owner/Operators are required to adhere to the Pre-Employment regulations for Drug & Alcohol Test. 

Add Pre-Employment Test {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Enter Zip Code {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }

RANDOM DRUG & ALCOHOL PROGRAM:

Important: As a self-employed driver (owner-operator, or O/O), you must use one or more consortia/third party administrators (C/TPAs) to manage the drug and alcohol testing program.

O/O must identify their C/TPA(s) in the Clearinghouse which automatically designates them and enables C/TPA to act on their behalf in the Clearinghouse, as required by CFR 382.705(b)(6).

By enrolling in the Random Drug & Alcohol Testing Program your company will use 'Hoffenmer' as your C/TPA (third-party administrator) to manage your Clearinghouse Portal, in fulfillment of CFR 382.705(b)(6).

{ binding firstError.message }
Clearinghouse Registration Processing Fee: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Clearinghouse Registration Processing Fee: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Total For Queries {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Random Enrollment - Employer Section {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Driver count: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Random Program Fees {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }

 

 

SIGNATURE & AGREEMENT


 

EXPEDITE {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

Expedited requests are completed the following business day. 

Otherwise, process of Clearinghouse registration is offered on a first-come first-served basis.

 

 

 

 

CLEARINGHOUSE REGISTRATION PROGRAM AGREEMENT CLEARINGHOUSE REGISTRATION TERMS AND CONDITIONS - PLEASE CLICK THE LINK TO REVIEW THE TERMS AND CONDITIONS.

I HAVE READ AND AGREE TO CLEARINGHOUSE REGISTRATION TERMS AND CONDITIONS {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Name of Person Completing This Application: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Job Title  {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Signature Only {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
If Other, Please Type In Your Job Title: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Today's Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

 

 

Additional Comments: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }

 

 

Asst Agent {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }