Dealers LP Equipment Company - Online Services Authorization Form

Thank you for your interest in the online services available through the Dealers LP Equipment Company web site.

For your protection, please confirm that the following person, who requested a User Name and password to access these services on your behalf, is authorized to do so: Name:     User ID:

Please complete the form below and email it to helpdesk@remichel.com or fax it to 410-553-0612. You can also mail the form to the following address:

Dealers LP Equipment Company One R.E. Michel Drive Glen Burnie, MD 21060 ATTN: Internet Authorization - IT Dept.

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Legal Name of Company:_________________________________________________________

DBA (doing business as):_________________________________________________________

Account Number: 0

Address:_______________________________________________________________________

Phone Number:__________________________________________________________________

City:_______________________________________ State: ________ Zip: __________________

Signed By:_______________________________________________________________________

Printed Name:_______________________________________________________________________ (Officer, Owner, General Partner, please)

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