If you are human, leave this field blank.DEALER ENROLLMENT FORMRequired:FranchiseNon-FranchiseDealership Name *DBAAddress *City *State *--Select--AlabamaAlaskaArizonaArkansasCalifornia Colorado Connecticut Delaware Florida Georgia Hawaii Idaho IllinoisIndiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin WyomingZip Code *Phone *FaxEnrollment Date *Federal Tax ID Number *Years in BusinessWebsite Dealership PersonnelEnter All That Apply. Dealer Principal NameDealer Principal EmailIs the Dealer Principal an F&I User?--Select--YesNoService Manager NameService Manager EmailIs the Service Manager an F&I User?--Select--YesNoF&I Manager NameF&I Manager EmailIs the F&I Manager an F&I User?--Select--YesNoOffice Manager NameOffice Manager EmailIs the Office Manager an F&I User?--Select--YesNoPrimary Contact NamePrimary Contact EmailIs the Primary Contact an F&I User?--Select--YesNoOther Authorized F&I Express System User NameOther Authorized F&I Express System User EmailOther Authorized F&I Express System User NameOther Authorized F&I Express System User EmailDo you currently have an F&I Express Account? *--Select--YesNo Dealership PaymentsPayment Type *CheckElectronic Funds Transfer (each payment initiated by dealer) Dealership SystemsDealer DMS System Utilized *Menu System Utilized, if any Dealership ProfitWould you like the Sales System to include a default profit for you? *--Select--YesNoIf yes, how much dollar mark-up do you want? $____________ Notes Agent InformationKISS BDM Name *BDM# * Other Documentation RequiredSubmitting this Dealer Enrollment Form will allow the Modern Auto Protection administrator to begin the enrollment process. However, the enrollment process cannot be completed until the dealer submits a signed and executed Dealer Producer Agreement and W-9.Submit 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