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Data Transmittal Form

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Application for SEC EDGAR Access Codes (US-based Entity)

* indicates required item.

* Entity Name:

Mailing Address

* Address Line 1: Address Line 2: * City: * State: * Zip:

Business Address (if different from mailing address)

Address Line 1: Address Line 2: City: State: Zip:
* Phone: Tax Identification Number: Doing Business As: Foreign Name:
State or Country of Incorporation: Fiscal Year End:
* Contact Person Name:

Contact Person Address (if different from mailing address)

Address Line 1: Address Line 2: City: State: Zip:
* Contact Person Phone: Email:

Individual signing for the entity

* Name: * Title/Position:

Payment Information

Cost: $145

* 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

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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.