I signed up Derek.
My quick
Your form wants a soc sec # and I don't give that out ever. Give the option for a tax id.
Your form also has a 25 character limit on the address. My business address is a P.O. box and with 1 address line I need more than 25 chars.
.....and now it's been almost 5 minutes since I signed up and no email yet... I'll update the post in a few....