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Name

First Last

Firm Name*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Fax

Email*

Authorized Contact Person at Your Firm*

Name

Business Tax ID Number*

Type of Business*

State-Issued Funeral Establishment License Number*

(Please fax a photo copy of state-issued license to 866.785.0030 or email to Accounts@CJF.com)

How did you hear about C&J?*

Has your firm previously used an assignment funding company?*

The funding fee is a cashless transaction that is deducted from the amount assigned. How is the fee going to be handled by your firm?*

If referred by another funeral home client, please let us know who:

Referring Sales Representative

Preferred Method of Payment*

Direct Wire Transfer ($20 wire fee) - Funds are wired to your bank for immediate use.
ACH Deposit - Funds deposited for next business day credit. Holidays and weekends will delay receipt of funds.

Additional Information, Requests, or Promo Code:

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