Legal Business Name *

Company "DBA" Name *

Platform Display Name *

This is the name that will appears as the header within the platform for the organization

Company Contact First Name *

Company Contact Last Name *

Company Phone Number *

Company Primary email

Address

Street Address

The official mailing address for your company

City

State

Country

Postal Code

Company Website

Please list your company's website URL or "N/A" if your company does not have one

Company Business License Number *

Medicaid Provider ID *

Please list your Medicaid Provider ID or "N/A" if your company does not have one

Company National Provider Number (NPI) *

Please list your NPI or "N/A" if your company does not have one

Company Federal Employer ID Number (FEIN) *

Please list your FEIN or "N/A" if your company does not have one

Secretary of State Business: Entity ID *

Please list your Entity ID or "N/A" if your company does not have one.

How many current drivers do you have? *

How many current Vehicles do you have? *

User List

Please list the users that will need access to ProCredEx for Credentials Management. Users will have access to all driver and vehicle information. Please include names and email addresses.

Driver and Vehicle Rosters

Please upload in Excel, Word, or PDF format: Driver Roster: Include Legal Name, Date of Birth, & Last 4 SSN Vehicle Roster: Include Complete VIN, Year, Make, & Model

Your Name *

The name of the individual completing this form

Your Title *

The title of the individual completing this form

Your Signatures *

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