TELEMARKETER APPLICATION FORM

Missouri Attorney General Jay Nixon

Call toll-free: 1-866-289-9633

Application is hereby made to obtain access to the No Call Missouri list. Please complete, sign and mail this form to:
Missouri Attorney General's Office
No Call Missouri
P.O. Box 861
St. Louis, MO 63188

ORGANIZATION
Name of organization
Street address
City		State		Zip
Phone		Fax
Name of affiliates or subsidiary companies associated with your company:			Phone number:

REGISTERED AGENT
Name of registered agent for service of process
Street address
City		State		Zip
Phone		Fax
List any trade, assumed or fictitious name used by applicant:			Phone number:

APPLICATION FEE
Sign and mail the completed application along with a check or money orderfor $50 for each area code per quarter to:	Attorney General Jay Nixon No Call Missouri 720 Olive St., Suite 2150 St. Louis, MO 63101
Payment is enclosed for: (Place a check mark for area codes wanted and a check mark for a full year or selected quarters. Quarters are based on a calendar year.) If you want all six area codes for one quarter, cost is $300. All area codes for one year will cost $1,200.	All area codes (or) 1 year (or) 314 636 Quarter 1 417 660 Quarter 2 573 816 Quarter 3     Quarter 4
A CD will be mailed for each quarter requested. If correct payment is not sent, application will be returned.

CONFIDENTIALITY AGREEMENT
I/We will comply with sections 407.1095-407.1113 RSMO and any rules promulgated thereunder, including but not limited to the use of this list for the sole purpose of complying with this law. I/We will notify the Missouri No Call Register within 30 days of any material change relative to this application or information contained therein. Having been duly sworn, and under the penalties of perjury, I hereby certify that the representations in this application and all attachments are true and correct to the best of my knowledge and belief.
Name of company
Signature of authorized representative		Title		Date