EDGAR Services and SEC Filer Resources
Data Transmittal Form

Use this form to send us your information securely.
Your data is protected for secure transmission using SSL/TLS encryption.

Application for SEC EDGAR Access Codes (Entity)

* indicates required item.

* Entity Name:

Mailing Address

Location (country): US Canada Other
 * Address Line 1: Address Line 2: * City: * State: * Zip: * Province: * Postal Code: * Postal Code: * Country:

Business Address (if different from mailing address)

Location (country): US Canada Other
 Address Line 1: Address Line 2: City: State: Zip: Province: Postal Code: Postal Code: Country:
* Entity Phone: * Entity Phone: US Tax Identification Number: Legal Entity Identifier: Doing Business As: Foreign Name:
State or Country of Incorporation: Fiscal Year End: Website:

Account Administrator #1

* First Name: Middle Name: * Last Name: Suffix: * Title:
Address (if different from Mailing Address) - Country: US Canada Other
 Address Line 1: Address Line 2: City: State: Zip: Province: Postal Code: Postal Code: Country:
* Phone: * Phone: * Email (Login.gov ID):

Account Administrator #2 (if not a single-person entity)

First Name: Middle Name: Last Name: Suffix: Title:
Address (if different from Mailing Address) - Country: US Canada Other
 Address Line 1: Address Line 2: City: State: Zip: Province: Postal Code: Postal Code: Country:
Phone: Phone: Email (Login.gov ID):

Billing Contact (if different from Account Administrator #1)

First Name: Middle Name: Last Name: Suffix: Title:
Address (if different from Mailing Address) - Country: US Canada Other
 Address Line 1: Address Line 2: City: State: Zip: Province: Postal Code: Postal Code: Country:
Phone: Phone: Email:

Authorized Signatory (if different from Account Administrator #1)

First Name: Middle Name: Last Name: Suffix: Title:
Address (if different from Mailing Address) - Country: US Canada Other
 Address Line 1: Address Line 2: City: State: Zip: Province: Postal Code: Postal Code: Country:
Phone: Phone: Email:

Payment Information

Cost:

* Credit/Debit Card#: * Expiration: * CVC:
* Name on Card:
Billing Address:
Message:

Advanced Computer Innovations, Inc.
70 Office Park Way • Pittsford, NY 14534-1746
Phone: 585-310-1740

EDGAR® and SEC® are trademarks of the U.S. Securities and Exchange Commission.
Advanced Computer Innovations, Inc.’s products and services are not affiliated with or approved by the U.S. Securities and Exchange Commission.