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Y.. <br />? MilllbL 140 N. Mitchell Ct., Suite 200 <br />Addison, IL 60101-5629 <br />7e1:(800) 341-6052 <br />FRANCOTYP-POSTALIA Fax: (800) 810-3768 <br />? www.fp-usa.com <br />Customer Information <br />Billing Address <br />Customer: <br />Department: 4- <br />Streei: <br />City: County: <br />State: ZiP= <br />Tel: <br />- Fax: <br />Email: - rContact Name: <br />Tax ID: <br />0 Tax Exempt certificate attached <br />Monthlv Rental Payment Terms <br />Ren#al Agreement <br />D-New Customer ? Renewal <br />? Change of Ownership <br />? Upgrade from <br />? Lease Company <br />Accoun: No: <br />Contract No: <br />Promo Code: <br />ShippingJ Installation Address <br />; <br />Customer. C,'?- <br />Department: <br />Street: -e' U " <br />Gity: ?-`? t ;7--d',? ???-? ?•..`, ? ; .?? C;ountY <br />State: Zip: <br />f{ i- <br />7e1: ••??., .- <br />f -- -. <br />Fax ?r'- <br />Email: <br />Conlact Name: ? <br />ti - ? <br />ment <br />gui Monthly Rate r :? 3Re,?tal}Bi f ,. ? <br />rQuan <br />ty p <br />? <br /> Annual Billing ? Semi Annual <br /> ?, <br />` ? <br />C6 J?1? <br />QuarterlyBilling ContractTerm <br />{ K ,?'"'\ - d?' 51z? r!w"2 F <br /> <br /> ? <br /> Please make check payable to CMRS-FP <br /> ` ment Enrollment <br />e Pa <br />Posta <br /> y <br />g <br /> Check No. <br />? <br />+ Unlimited Resets to be included ?p? <br />Amount ($) <br /> ? <br />?' Raie Guard to be included X.(i, ,{Re?urrir???P,?os?ge <br /> F] Reset Debit (Application Attached) <br /> <br /> l $ 0 On Demand Debit (Application Atiached) <br /> Total Monthly Renta <br />+ If unlimited resets is not checked above, I agree to pay the current list price for each occurrence. l (initials required) <br />++ Rate Guard has been explained to me, and 1 have elected to ? Enroll Lj Not Enroll (initials required) <br />month rental term (initials required) `4 year initial term will apply unless otherwise selected. <br />"This agreement and the Terms & Conditions attached hereto shall automatically and without any further action by either party hereto, renew for one <br />year periods following the expiration of the initial term and any such renewal terms, unless and until either parry hereto provides written notice to <br />the other party of its intent to so cancel. Such written notice must be delivered no later than ninety (90) days (or the maximum time period permitted <br />by applicable law) prior to the end of the current term. Cancellation will be effective at the end of ihe current term. FP can change the monthly rate <br />and fees after the initial term, with 30 days prior notice. <br />Customer Acceptance <br />K ;UR Ni- <br />?Authorized Representative: i.: <br />_ (PqiM rvnME) ?i <br />Tel: . ti;;.' • ? - ?? ? ,?-',? <br />Drivers License No: State: ; <br />_,,-•? %..??' .,-?%'? <br />Authorized Signatur.g=??` <br />? <br />Title: <br />Date . ? <br /> <br />? Contract Station Meter - USPS Letter must be attached <br />:.Dealer.lnformation - <br />Dealer Number and Name: <br />Address: <br />Tel: -d ` -., - Fax- ? -- ---- -- <br />Sales Representative: <br />Approval by Francotyp-Postalia, Inc. <br />Rv1 MG RENTAGF Ot Page