Interstate National Dealer Services

	* Required Information
*Producer Name:
Producer Code:
*Producer E-mail address:
Producer Tax ID Number:
*Producer City:
*Producer State:

Participant Information

*First Name:
*Last Name:
*Mailing Address:
*City:
*State:
*Zip:
*E-mail Address:
*Phone Number:
Fax Number:
*Social Security #:	XXX-XX-XXXX
*Confirm Social Security #:	XXX-XX-XXXX
*Password:	(up to 10 characters)
*Unique Identifier: (first initial, last initial, last 3 of social security #)

Please ensure that all of the required information is entered prior to submitting your enrollment form. Missing information will prevent us from processing your enrollment and possibly delay reward points.

Terms and Agreement

Interstate Super Star Rewards Program Terms and Agreement. You must request enrollment to participate in the SuperStar Rewards Program by completing the aforementioned enrollment information. By submitting this enrollment form, you are notifying Interstate that your dealership has been advised and approves of your intent to participate in the SuperStar Rewards program. Interstate National Dealer Services, Inc. reserves the right to make final interpretations regarding all aspects of the program, including but not limited to the credit or debit of points, and their decision is final. Interstate National Dealer Services, Inc. also reserves the right to cancel or amend this program at any time without written notice.

I have read and accept the above Terms & Agreement.