Confirmation of Broker Agent Agreement

This document is a confirmation of an existing agreement between the Broker Agent and Authorizing Company listed below.

This is a binding document and will be considered proof of an agent agreement. It will be considered permission to use the authorizing company's authority in the establishment of an account for the benefit of the agent. If the agent agreement is terminated, DAT must be notified in writing within 24 hours of contract termination.


* Required Field
Broker Agent
First Name: *
Last Name: *
Title: *
Email: *
Company Name: *
Street Address: *
City: *
State: *
Zip Code: *
Phone #: *
Fax #: *
Authorizing Company
Company Name: *
MC #: *
First Name: *
Last Name: *
Title: *
Email: *
Phone #: *
Fax #: *
Street Address: *
City: *
State: *
Zip Code: *
* Required Field

Contact Us

  • DAT Compliance Team
  • P.O. Box 23519
  • Portland, OR 97281-5081
  • Phone: 800-547-5417
  • Fax: 800-280-2475
  • customer.support@dat.com
  Newsletter Sign Up  
I am a:
 
 
I have read and accept the DAT Solutions privacy policy. By clicking subscribe I acknowledge that I want to receive emails from DAT.