Texan Local — Enrollment Form

Client Information

Business Name (Legal)*

Required

DBA / Trade Name

Street Address*

Required

Contact Name*

Required

City*

Required

State*

Required

ZIP*

Required

Phone #*

Required

Cell #

E-Mail*

Valid email required

Package Selection

Term Package*

Limited6 mo Premium12 mo Elite24 mo

Zone	Product Type	Start Month	Rate/Mo		Zone	Product Type	Start Month	Rate/Mo
01-NBE					05-SCG
02-NBW					06-TPC
03-BSB					07-STP
04-SMW					08-DSB

Notes:

Payment Authorization

💳 Credit Card

🏦 ACH / Checking

Card Type*

Required

Card Number*

Required

Name on Card*

Required

Exp Month*

Required

Exp Year*

Required

Billing Address*

Required

ZIP / CSV*

Required

★ A 4% service fee will be added to all credit card payments.

Initials:

Routing Number*

Required

Account Number*

Required

Account Holder Name*

Required

Account Type*

Required

By providing your bank information, you authorize Knight Dynamic Solutions, LLC to initiate electronic debits from your account on approximately the 20th of each month for the duration of this agreement.

Initials:

★ Unpaid balances (including declined CC) will incur a fee of the greater of $50 or 10% per month.

Add-Ons & Payment Summary

Setup Fee (one-time fee)$

Premium Placement$/mo

Call Tracking$/mo

$/mo

Call Tracking FWD #

Subtotal

Sum of all zone monthly rates

$0.00

First Month Payment

Subtotal + Setup Fee + Add-Ons

$0.00

Monthly Charge (after initial month)

Subtotal + ongoing add-ons

$0.00

Client Initials:

Advertising Enrollment Agreement