Registration Form
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Registration Form
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STAAB AGENCY / Shirley St. Pierre / Statutory AgentP O Box 942, Jefferson Me. 04348 1-800-648-8805Re-Registration And New Registration FormName to appear on registration:_______________________________________________ Address where to send registration:___________________________________________ City:_______________State:____Zip:_______Person to Contact____________________ Telephone:_______________________________Fax:_________________________________ Comments:_____________________________________________________________________ ______________________________________________________________________________ Federal ID#:_______________________________ Date of Birth:____________________ Unit# YR. Make Serial/VIN# Plate# Yrs. 1._____________ ____ ________ ____________________ ___________ _______ 2._____________ ____ ________ ____________________ ___________ _______ 3._____________ ____ ________ ____________________ ___________ _______ 4._____________ ____ ________ ____________________ ___________ _______ 5._____________ ____ ________ ____________________ ___________ _______ 6._____________ ____ ________ ____________________ ___________ _______ 7._____________ ____ ________ ____________________ ___________ _______ 8._____________ ____ ________ ____________________ ___________ _______ 9._____________ ____ ________ ____________________ ___________ _______ 10._____________ ____ ________ ____________________ ___________ _______ 11._____________ ____ ________ ____________________ ___________ _______ 12._____________ ____ ________ ____________________ ___________ _______ 13._____________ ____ ________ ____________________ ___________ _______ 14._____________ ____ ________ ____________________ ___________ _______ 15._____________ ____ ________ ____________________ ___________ _______ WE ACCEPT VISA/MASTERCARD |
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Send mail to staab@staabagency.com
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