Business Company Application

BUSINESS COMPANY APPLICATION

Applicant Name:   Doing Business As:

Company Name:   Company Contact:

RECITALS

WHEREAS Applicant Name: seeks authorization to register, contract with, or receive services from Company Name: for the business activities described herein;

WHEREAS the parties intend this Application to serve both as an informational submission and as an agreement governing the provision of specified services upon acceptance and execution by an authorized representative of the Company;

WHEREAS Applicant warrants that all information supplied in this Application is true, complete, and provided for the purpose of evaluation and contractual offer.

BUSINESS INFORMATION

Corporation LLC Partnership Sole Proprietorship Other:

PRINCIPAL OFFICERS AND OWNERSHIP

BUSINESS DESCRIPTION

DOCUMENTS AND REFERENCES

Articles of Incorporation / Formation Operating Agreement Recent Financial Statements

EIN Confirmation Other:

PAYMENT TERMS

Applicant agrees to pay Company the fee described below for services accepted under this Application. Payment obligations commence only upon Company acceptance and execution of this Application.

All sums not paid when due shall bear interest at the rate specified above and Applicant shall be liable for costs of collection, including reasonable attorneys' fees and court costs. No credit shall be extended except as expressly provided in writing by Company.

TERM AND TERMINATION

This Agreement, if accepted by Company, will become effective on Start Date: and will continue until End Date: unless earlier terminated in accordance with this Section.

Either party may terminate for cause upon written notice if the other party materially breaches any provision and fails to cure within the notice period specified above. Termination shall not relieve Applicant of obligations to pay for services performed through the effective date of termination or for any non-cancellable commitments made prior to termination.

CONFIDENTIALITY

Each party acknowledges that in the course of evaluation and performance under this Application it may receive Confidential Information from the other party. Confidential Information means non-public business, technical, financial or operational information disclosed in any form. Each party shall: (a) hold the other party's Confidential Information in strict confidence; (b) not disclose it to any third party except as expressly permitted; and (c) use it solely for purposes of performance hereunder. Confidential Information does not include information that is or becomes publicly available other than through a breach of this clause, or that is lawfully obtained from a third party without restriction.

GOVERNING LAW

This Application and any resulting Agreement shall be governed by and construed in accordance with the laws of the state of without regard to its choice-of-law principles. Venue for any dispute shall be in the state and federal courts located in the county in which Company has its principal place of business.

ENTIRE AGREEMENT

This Application, together with any exhibits, schedules, attachments and the written acceptance by Company, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, understandings, negotiations and representations, whether oral or written. Any modification must be in writing and executed by authorized representatives of both parties.

CERTIFICATION AND AUTHORIZATION

By signing below, Applicant certifies under penalty of perjury that the information provided in this Application is true, correct and complete to the best of Applicant's knowledge, and that Applicant is authorized to execute this Application on behalf of the Applicant entity. Applicant authorizes Company to verify information provided and to obtain credit, banking and other references.

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