4179 West Irving Park Road, Chicago, IL 60641-2906, (773) 777-0707 or (800) 877-3624, Fax:  (773) 286-1992

DEALER ACCESS CODE AUTHORIZATION FOR SECURE INTERNET SERVICES
Please Complete This Form and Fax It to EM24 
Secure Internet Services include “Pet on the Net”, Viewing Account Activity Reports, Account Data and Reserved Accounts and Interactive Services such as entering and changing Subscriber Account Information and Placing Accounts on Test..

I authorize the following Dealer Secure Access Code(s) for my company:

FIELD DESCRIPTIONS & INSTRUCTIONS
Passcode: Enter your six digit passcode, must be a combination of alpha/numeric with a minimum of six characters and maximum of 40 characters.
User Name: Enter the first and last name of the individual to whom access will be given.
User Email: Enter Email address of the individual.
User Level: Enter access level for individual to whom access will be given (see access levels below).
Lock Email: Enter “yes” or “no” to determine whether the user logging on can change Email address confirmation without prior approval.

SECURE INTERNET SERVICE ACCESS LEVELS
Full Access: Can access all the Dealer’s Secure Internet Services data including Interactive Services, Implement Subscriber Request, View Information, Service Request and Print Services. Can search for subscriber by name and view a list of all subscribers.
Limited Access: Must use a specific account number to access the Dealer’s Secure Services data including Interactive Services, Implement Subscriber Request, View Information, Service Request and Print Services. Cannot use search functions and cannot view a list of all subscribers. Access is limited to known account numbers.
View Only: Can only access to View Information and Print Services.
Limited View: Can only access to View Information but the Account Passcode is blocked.
Notify: This Email is the general Email notification from EM24.
Data Entry Ticket Alert: Will receive Email notification when a Data Entry Ticket is entered.

I understand that access code(s) may be added or deleted by submitting a Dealer Access Code Change Form and that such form(s) must bear the same name and signature as the authorized name on this form. No verbal changes will be accepted. All additions and changes will be made within two to three business days after receipt of all forms.

                                                                                                             
DEALER #                                         COMPANY NAME
                                                                                                                                              
PRINT/TYPE AUTHORIZED NAME
                                                                                                                                             
AUTHORIZED SIGNATURE                                                                             DATE