Individual Customer Page

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Individual Customer Account Information
* Denotes Required Field
Mr./Mrs./Ms.:
First Name:	*
Middle Initial:
Last Name:	*
Jr./Sr./etc.:
Doing Business As:
		Phone number format: 999-999-9999 * at least one phone field is required.
Work Phone:
Home Phone:
Cell Phone:
		Fax number format: 999-999-9999
Fax:
Email:
		User IDs can be a combination of letters and numbers and must have between five and sixteen characters. Passwords must be at least five characters. Both are case-sensitive.
User ID:	*
Password:	*
Confirm Password:	*
		When contacting the DOT/PF by phone or in person, you will be asked a question to verify your account. Please provide a question and answer that are unique to you. Verification Question is the question that you want the DOT/PF to ask to help identify you as the account holder, e.g. "What is your mother's maiden name?"
Verification Question:	*
		Verification Answer is your response to the question.
Verification Answer:	*

Mailing Address
Address	*
Address cont.
City	*
State	*
Zip	*	ZIP code format: 99999 or 99999-0000

Physical Address
		Same as Mailing
Address
Address cont.
City
State
		ZIP code format: 99999 or 99999-0000
Zip
Billing Address
		Same as Mailing
Address	*
Address cont.
City	*
State	*
		ZIP code format: 99999 or 99999-0000
Zip	*

Submit: sends your account information to the system.
Reset: sets all the fields to blank without saving/submitting any current information.
Cancel: exits to the Welcome page without saving/submitting any current information.