Customer Entry Form
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Customer Entry Form
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MAIN ENTRY FORM
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Full Name (customer 1)
*
NV Drivers License #
Date of Birth (customer 1)
Place of Birth (customer 1)
Physical Street Address
Physical City, State, Zip
Physical Address County
Mailing Street Address
Mailing City, State, Zip
Mailing Address County
Full Name (customer 2)
NV Drivers License # (customer 2)
Date of Birth (customer 2)
Place of Birth (customer 2)
Physical Street Address (customer 2)
Physical City, State, Zip (customer 2)
Mailing Street Address (customer 2)
Mailing City, State, Zip (customer 2)
Phone (customer 1)
Email (customer 1)
*
VIN Number
Year (vehicle)
Make
Model
Body Type
Odometer
Color
Fuel Type
Weight (trailer)
GVWR
Axles
Exemption number
Other (forms)
Out of state plate number
Permit (days)
Permit reason
Plate surrender
Plate type
Credit Card Number
CC Expiration month
CC Expiration Year
Payment Amount
Payment Amount Written Out
Date (payment)
NV Plate Number
Seller Full Name
Seller NV DL Number/DOB
Seller Street Address
Seller City, State, Zip
Service Type
Smog
NP
TT
IL
DT
DR
RW
ORW
Permit
PC
PS
Other
Smog Pass Fail
Pass
Fail
DMV Estimate
Service Charge
Total
Cash or Credit Payment
Cash
Credit Card
Estimated Delivery Date
Estimated Delivery Time
Today's Date
Business Name
*
Phone Number
*
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