Affirmation Signature

In the event you missed our required identity verification form on the back of our mailing kit brochure, simply click on the link below. Please print, complete, and fax the form to 954-212-0808.

Remember that we will not be able to evaluate your items unless we receive this information from you.

Download Form

*First Name:
*Last Name:
*Address:
Apt/Suite:
*City:
*State	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
*Zip Code:
*Email:
Phone:
I certify that I have read and agree to the Terms & Conditions *Required