Apply to be a Chancellor, Inc. customer
Our Customer qualification process has two steps:
1. Submit a Credit Application and Agreement form.
2. Provide your permit certification.
Provide your permit certificate by uploading it below or emailing it to John Thaxton, firstname.lastname@example.org
To upload your permit certificate, click “Upload” to locate the form on your desktop
Click “Submit Form” to send us your certificate.
To open the document, click the PDF icon above. You can print the form or if you have adobe reader (a free application) you can save the form and type directly into it. Please keep in mind that a signature is required in order for the form to be considered complete.
Please email completed application and tax forms to: