Your Name/Firm Name:

Contact Name:

Firm Address:

Firm City & State:

Firm Zip Code:

Email:

Phone:

Fax:

Documents:

Other:

Would you like LPS to cut your
Witness Fee Check for you?:

Witness Fee:

Handling:

Who are we serving?

Name of entity to be served:

Resident Agent:

Attorney Info:

Address 1:

City & State:

Zip Code:

This address is a:

Name of Business:

Do you have additional addresses?

Address 2:

City & State:

Zip Code:

This address is a:

Name of Business:

Phone:

Do you have additional phone numbers?

2nd Phone:

3rd Phone:

Date of Birth:

Social Security Number:

Sex:

Height:

Weight:

Color of Skin:

Hair Color:

Eye Color:

Vehicle:

Paying by:

Special instructions or
additional information:

Will Send to LPS by:

Would you like LPS to file the Affidavit of Service in the applicable Nevada court of jurisdiction? **Additional Fee Will Apply

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