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Customer Aqreement <br />Billing Address <br />, - <br />? Department: <br />? <br />Street: 1.? L C?`' ^, <br />City: County: ----- <br />State: ? -- <br />Z;v <br />TeI, =+-t10 Fax c <br />E-mail: <br />Contact Name: <br />Deliver To: Dealer p Customer ? Fulfilletl from Dealer inventary <br />RENTAL INPORMATInN <br />Shipping 8 Installation Address (if arherent tnan eiuing) <br />Customer. <br />Department <br />Street <br />FA Mailing Solutions <br />140 N Mitchell Ct, Ste 200 <br />Addison, IL 60101-5629 <br />Tel 800341.6052 <br />CitY ? Counry: -- <br />Siate: j Zip: <br />Tel: Fax: <br />E-mail: <br />i Conlact Name: <br />' Mailing Address. `&?Same as Billing ? Same as Shippingllnstallation <br />Quantity Item # Item Descdption Monthly Rate Rental Bifling Delivery {seiect one) <br />? 1'"i"ot ? ?=?,? (c,?'.; !-? •?S ? Electronic Bilfing <br /> Paper Billing <br /> Rental Billing Frequeney (sefecf one) <br /> ? Annual6ilfing <br /> ? Semi-Annual <br /> ? Quarterly Billing <br /> <br />Term of Contract: ? months <br />__z Total Monthfy Payment $ <br />CJ Temu and Condilions: By signing below, i hereby acknowledge and agree ihat FP's standard shipoing rates and ihe atlditional lerms and conditions available on ihe FP website al www.ip-usa,camrtemu-contlitions are <br />applicatle to, and incorporatetl by reterence intq this agreernenL (If you do not have access to the intemel, please contact FP di2ctly at 800 341 .6052 and we vnll proride you with a copy for your records.) <br />_CUSTOMER ACCEP7pNCE <br />Customer Acceptance of Terms Dealer Information <br />thorized Re resenla6ve: Dealer Name: <br />-?---- - - - _ - ?-t ?l Dealer <br />-T-eh"' <br />Address I <br />'_ State: ? Tel: l„? `-t t <br />Signature: X? ? Sales Representative Nan <br />Sales Representalive: A <br />)EALER 8 INTERNAL U5E ONLY <br />? New Customer <br />? Lease Company: <br />[? Upgrade From: :.t t tVV ? MajorAccount <br />? Renewal (no change otequipment) ? GSA Contract No,: <br />? Change o! Ownership 0 State Contract No.: <br />Existing Account No_ Master Billinq Acct No.: <br />Existing Contract No.: Master Pos[age AaL No : <br />Faz: L?'L.t %•_.? i f) -7 <br />-r ?;. <br />r"1 :- 'r Y?:?L• '_'t <br />_l <br />I Date: <br />Promo Code <br />? Price or Terms Exception Approval (atlach copy) <br />Navision No,: <br />[] USPSO Location: (letler must 6e aftached) <br />El Tax-Exempt Certificale Attached <br />Addf6onal Terms: <br />FM_MG_RENTAGR_70 P89e 1 <br />reviSea 0110712013