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CONSUMER DATA ORDER FORM
PATRIOT INSURANCE GROUP
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* Indicates required question
DATE:
*
Your answer
AGENT NAME:
*
Your answer
CUSTOMER TYPE:
*
Choose
New User
Existing User
Email Address
*
Your answer
PHONE NUMBER:
*
Your answer
LIST DELIVERY OR UPLOAD PREFERENCE:
*
Location where you would like for your lists to be delivered or uploaded .
PatriotDialer Plus Upload (CRM account owners only)
Email
PREFERRED GEOGRAPHY
*
State
County
Zip Codes
Required
TARGET AREA(s) FROM ABOVE:
*
Your answer
NUMBER OF RECORDS (.035 per count - minimum order $50.00):
*
Choose
1428 Records $50.00
2142 Records $75.00
2857 Records $100.00
3571 Records $125.00
4285 Records $150.00
5000 Records $175.00
AGE RANGE (RECOMMENDED 45-85):
*
Your answer
INCOME RANGE (RECOMMENDED $25,000-$60,000):
*
Your answer
CREDIT CARD TYPE:
*
Choose
VISA
MASTERCARD
NAME ON CREDIT CARD:
*
Your answer
CREDIT CARD NUMBER:
*
Your answer
EXPIRATION DATE:
*
Your answer
3 DIGIT SECURITY CODE:
*
Your answer
ADDRESS ON CREDIT CARD:
*
Your answer
CITY/STATE/ZIP ON CREDIT CARD:
*
Your answer
ADDITIONAL NOTE OR MESSAGE:
Your answer
TERMS AND CONDITIONS
*Terms and Conditions – by submitting this form you understand that this amount will be charged to your credit card and you agree to the following terms.. Minimum order $50.00.
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