Customer Credentialing Forms

Use these forms as you complete the Customer Credentialing process.

Contract/Administrator Information

ValueDescription
Last NameEnter the administrator’s last name.
First NameEnter the administrator’s first name.
M.I.Enter the administrator’s middle initial.
Job TitleEnter the administrator’s job title.
Telephone numberEnter the administrator’s phone number. Do not include dashes.
Email addressEnter the administrator’s email address.
Date of birthEnter the administrator’s date of birth (MM/DD/YYYY).
Complete Home AddressEnter the administrator’s address. Include street, city, state, zip.

Sole Proprietors or General Partners Information

ValueDescription
NameEnter the contact’s first and last names.
Date of birthEnter the contact's date of birth (MM/DD/YYYY).
Complete Home AddressEnter the contact's address. Include street, city, state, zip.

Site Visit Contact Information (optional)

Site visits may be required to assure eligibility for LexisNexis products or services. By submitting this application, you agree to authorise a site visit by LexisNexis or its approved third party and to cooperate in its completion. Please provide the name of a contact for the site visit, if different than contacts already provided.

ValueDescription
Contact Full NameEnter the contact’s full name.
Contact PhoneEnter the contact’s phone number. Do not include dashes.
Contact EmailEnter the contact’s email address.

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