Customer Number Form

CUSTOMER NUMBER FORM

Client Name:    Company Name:

Effective Date:

Recitals

WHEREAS, Client has requested that Company establish a unique customer number to be used for identification, billing, ordering and account administration; and

WHEREAS, Company is willing to assign such customer number and to provide related account setup and administrative services upon the terms and conditions set forth in this Customer Number Form (the "Form");

WHEREAS, the parties intend for this Form to govern the assignment of the customer number and the associated responsibilities of each party as set forth below.

Assignment of Customer Number

The Assigned Customer Number is provided for use in invoicing, purchase orders, account inquiries and related administrative activity. Client acknowledges that Company retains discretion to change or reassign the number for account management reasons upon written notice to Client.

Account Information

  Individual      Corporation      LLC      Partnership      Other

Scope of Work / Use of Account

Payment Terms

Invoice Amount:    Payment Schedule:

Late Payment: If payment is not received within the agreed payment period, Client shall pay interest at the rate of or a late fee of , whichever is greater.

Term and Termination

Term Commencement Date:    Term Expiration Date:

Either party may terminate this Form for convenience upon days' prior written notice. Termination for material breach by either party may be effected immediately upon written notice where the breach remains uncured after a reasonable cure period not to exceed 30 days.

Confidentiality

Each party acknowledges that in the course of performance it may receive Confidential Information of the other party. "Confidential Information" means non-public information disclosed in any form that is designated confidential or that a reasonable person would understand to be confidential given the nature of the information and the circumstances of disclosure. Each party agrees to: (a) use Confidential Information only for purposes of performing its obligations under this Form; (b) protect Confidential Information with at least the same degree of care it uses to protect its own confidential information but in no event less than reasonable care; and (c) not disclose Confidential Information to any third party except to its employees, agents or contractors who have a need to know and who are bound by confidentiality obligations at least as restrictive as set forth herein.

The obligations of confidentiality shall continue for a period of years following termination or expiration of this Form, except with respect to trade secrets for which protection shall be for so long as the information qualifies as a trade secret under applicable law.

Governing Law

This Form shall be governed by and construed in accordance with the laws of the State of without regard to conflict of laws principles. The parties submit to the exclusive jurisdiction of the state and federal courts located within that State for any dispute arising out of or relating to this Form.

Entire Agreement

This Form, together with any exhibits or schedules agreed in writing and executed by the parties, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, proposals and communications, whether written or oral, with respect to such subject matter. No amendment or modification of this Form will be effective unless in writing and signed by authorized representatives of both parties.

Acknowledgment and Certification

By signing below, Client acknowledges receipt of the Assigned Customer Number and certifies that the information provided in this Form is true, complete and accurate to the best of Client's knowledge. Client agrees to comply with the payment terms, confidentiality obligations and other provisions of this Form.

Accept Terms:   I certify and accept the terms of this Customer Number Form.

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