Member Registration

Username & Password

Username:

Password:

Confirm Password:

E-mail Address:

Identifying Information

Last Name:

First name:

Middle Initial:

Title:

Degree:

SSN:

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Driver's License #:

Driver's License State:

Professional License Information

License Type:

License Number:

Expiration:

Office Contact Information

Primary Office/Organization:

Office Street Address:

Office Address 2:

Office City:

Office State:

Office Zip:

Office Phone:

Ext:

Office Fax:

Home Contact Information

Home Street Address:

Home City:

Home State:

Home Zip:

Home Phone:

Preferred Mailing/Contact Address

Preferred Contact:

Office Home

Checking Account Information

Bank Name:

Bank Street Address:

Bank Address 2:

Bank City:

Bank State:

Bank Zip:

Bank Phone:

Bank Account Number:

Bank Routing Number:

Robot Check

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Agreement Acknowledgment

By checking this box and registering with ProfessionalCharges.com, you are indicating that you have read and accepted our Member Agreement. This is a binding contract between you and ProfessionalCharges.com and it contains important provisions regarding, among other things, responsibilities, indemnities, limitations on liability and restricted and prohibited uses of our service. You will not be able to use our services unless you agree to this Member Agreement (Links will open new browser window). I further authorize ProfessionalCharges.com to debit my bank account for the annual membership fee. Click on the agreement statement below to complete the registration.