Dealer Enrollment Form

Required:

Franchise

Non-Franchise

Dealership Name *

DBA

Address *

City *

State *

Zip Code *

Phone *

Fax

Enrollment Date *

Federal Tax ID Number *

Years in Business

Website

Dealership Personnel

Enter All That Apply.

Dealer Principal Name

Dealer Principal Email

Is the Dealer Principal an F&I User?

Service Manager Name

Service Manager Email

Is the Service Manager an F&I User?

F&I Manager Name

F&I Manager Email

Is the F&I Manager an F&I User?

Office Manager Name

Office Manager Email

Is the Office Manager an F&I User?

Primary Contact Name

Primary Contact Email

Is the Primary Contact an F&I User?

Other Authorized F&I Express System User Name

Other Authorized F&I Express System User Email

Other Authorized F&I Express System User Name

Other Authorized F&I Express System User Email

Do you currently have an F&I Express Account? *

Dealership Payments

Payment Type *

Check

Electronic Funds Transfer (each payment initiated by dealer)

Dealership Systems

Dealer DMS System Utilized *

Menu System Utilized, if any

Dealership Profit

Would you like the Sales System to include a default profit for you? *

If yes, how much dollar mark-up do you want? $____________

Notes

Agent Information

KISS BDM Name *

BDM# *

Administrator

American Auto Shield, LLC • 1597 Cole Boulevard • Suite 200 • Lakewood CO 80401 • Phone 800-531-1925 X2297

• Email: info@modernautoprotection.com • Fax: 800-728-5065