Broker-Vendor Application

Broker Information

Broker Name

Broker's TPC Dealer Code

Broker Email

Vendor Business Information

Vendor Business Name

Vendor Address

Vendor City

State & Zip

Vendor Federal Tax ID

Vendor Yrs in Business

Duns Number

Business Alone

YesNo If no, you'll be required to enter valid Vendor Principal Information below

Vendor Contact Name

Position

Vendor Phone

Vendor Fax

Vendor Email Address

Vendor Business Type

Receive Email from TimePayment?

YesNo

Vendor Principal Information

Vendor Principal information is required if you are not submitting a Business Alone Application

Principal Name

Address

City

State & Zip

Title

SSN

Phone

Email Address

Vendor Equipment Information

Equipment Type

Do You Sell Used Equipment?

YesNo

Auth Distributor

Manufacturer

Comments

Authorization, Representations, and Warranties

Select "YES" in the following boxes if you agree:

In the event that I am seeking approval of a Referral Program Dealer, I hereby authorize and consent to TimePayment Corp. (hereinafter, "TPC") and its affiliates, regarding both the said Referral Program Dealer application, along with any resulting Customer account application, to investigate and/or obtaining credit reports, employment history, trade references and other information – including information that would validate the authenticity of the Referral Program Dealer’s bank account, which I have permission to provide to TPC for the purpose of TPC funding the approved equipment lease, equipment rental, or transactions.

I hereby certify that the information provided above is true and I agree to indemnify and hold TPC harmless from any and all damages, losses and liabilities incurred or suffered as a result of, or incident to, any action by persons other than TPC's employees. I also agree to use the system only for its stated purpose and that failure to do so may result in the immediate termination of my company's access to TimePayment InfoHub.

I hereby warrant and represent that: (a) When I, or my Authorized Users, receive signed applications for prospective TPC equipment lessees or equipment renters, (all herein referred to as, Customers), such customers credit applications shall authorize TPC to perform a credit check on those Customers and (b) to the best of my knowledge, the information provided in the Customer credit application shall not be false, inaccurate, or misleading.

Adopt this typed representation of my name and title as my signature.

Broker's Name

Broker's Title

Date Signed

By submitting this application I will be completing the signing process and this application will be submitted for credit approval. I agree that this will be an electronic representation of my signature. I further understand that by completing the signing process and submitting this document for credit approval, it will have the same legally binding effect as signing my signature using a pen and paper.

For questions or assistance with this form, please contact your Business Development Manager at 877-868-3800