Dover Enrollment Form

Status

Reason

Enroll Date

Win Date

Company*

First Name*

Last Name*

Title*

Email*

Street*

City*

State/Province Code*

Postal Code*

Phone*

Manager Name*

Manager Title*

Manager Email*

By submitting this document, you are agreeing that all payments from Dover to your Company will be made via Virtual Credit Card, in USD. Virtual Credit Cards will be delivered via email, from incontrol@mastercard.com, and should be immediately processed. Each Virtual Credit Card is a single-use credit card, and may apply to multiple invoices. Please let the Citi agent know if you have any card processing limitations that could impact your ability to process these credit card

Payment Remittance Email*

Tax ID

* Dover will not agree to a surcharge or a fee for paying with a virtual credit card.

* Contact us at Dover@info14.citi.com or call us at 877-345-6923. Our fax number is 855-859-6873.

If other buyers wish to pay you this way in the future, will your company accept their virtual credit card payments without fees or restrictions?*