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Data Transmittal Form

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Application for SEC EDGAR Access - for Entities

* indicates required item.

* Entity Name:

Mailing Address

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

Business Address (if different from mailing address)

Address Line 1:
Address Line 2: Location (country): US Canada Other
 * 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 (Primary Contact Person)

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

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

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

Billing Contact (if different from Account Administrator #1)

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

Authorized Signatory (if different from Account Administrator #1)

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

Payment Information

Cost:

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

Advanced Computer Innovations, Inc.
70 Office Park Way &bul; Pittsford, NY 14534-1746
Phone/Text/Fax: 585-510-3890 • Toll-free: 888-272-7184

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