Kansas Department of Revenue E-lien Site

Kansas Department of Revenue

Business Information

Business Partner's Name:

Mailing Address:

City:

State:

(two digit state code)

Zip:

Phone Number:

* *

(Must not contain - or (), exp. 5555555555)

Fax Number:

(Must not contain - or (), exp. 5555555555)

Business Partner's E-Mail Address:

Business Contact Name:

* *

Business Type:

Sole Proprietor
Partnership
Corporation
Limited Liability Co.
LTD Company
National Financial Institution
Limited Liability Partnership
Other

Associate Information

Associate's Name:

Select User Name:

(Must be 6 to 8 characters)

Last 4 digits of SS#:

* *

Date of Birth:

* *

(exp. mm/dd/yyyy - 01/31/2000)

Associate E-Mail Address:

Associate Phone Number

(Must not contain - or (), ex. 5555555555)

Associate Fax Number

* *

(Must not contain - or (), ex. 5555555555)

Security Questions (You must choose three different questions and provide an answer for each).

* *

Supervisors Name:

* *

Supervisors Position:

* *

Supervisors Phone Number

* *

(Must not contain - or (), ex. 5555555555)

Business Partner Registration:

Check one below: Dealer, Dealer/Lien Holder or Lien Holder Only.

Dealer Only *Choose this selection ONLY, if you are a Dealership who DOESN'T lend.

Dealer/Lien Holder *Choose this selection ONLY, if you are a Lien Holder but NOT a bank or Credit Union.

Lien Holder Only *Choose this selection ONLY, if you are a Bank or Credit Union.

Electronic Funds Information

Name of EFT Contact:

* *

Business Partner FEIN:

* *

Account Type:

Checking

Savings

Ledger

Bank Name:

* *

Bank Contact:

* *

Bank Phone Number:

* *

(Must not contain - or (), exp. 5555555555)

Transit/ABA Number:

* *

Account Number:

* *