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BUSINESS CONTACT INFORMATION


Payable Contact Person:
Title:

Company name:

Phone:
Fax:
E-mail:

Registered company address:

City:
State:
Zip:

Data business commenced:
Tax ID:

FORM OF BUSINESS


BUSINESS/TRADE REFERENCES


REFERENCE 1


Company name:

Address:

City:
State:
Zip:

Phone:
Fax:
E-mail:

Type of Account:

REFERENCE 2


Company name:

Address:

City:
State:
Zip:

Phone:
Fax:
E-mail:

Type of Account:

REFERENCE 3 (Optional)


Company name:

Address:

City:
State:
Zip:

Phone:
Fax:
E-mail:

Type of Account:

TERMS AND CONDITIONS


1. All amounts due must be received within credit terms. Credit hold status will be placed on all overdue accounts. Delinquent invoices are subject to a 5% service charge per month.

2. In the event of default, reasonable attorney fees and collection costs will be charged where permitted by law. If court involvement is necessary to settle an unpaid balance, jurisdiction will reside in Harris County, Texas.

3. All checks may be converted to an electronic (ach) payment. There will be a $50.00 service charge on all returned checks. I certify that the facts contained in this document are true and complete to the best of my knowledge. I hereby authorize the investigation of all references listed above to obtain pertinent information and understand that any information obtained will be held in strictest confidence.

4. My signature below authorizes full release of this information over the phone to Cybcar America, LLC. We agree to abide by all terms set on this application and authorize Cybcar America, LLC to review our personal and company credit information.

CREDIT CARD AUTHORIZATION FORM


I/We Authorize Cybcar America, LLC to charge my credit card.

For services rendered. Not to exceed the amount shown.    REFERENCE#

CREDIT CARD TYPE


CREDIT CARD #
CARD CV2 #

ISSUED DATE
EXPIRATION DATE

BILLING ADDRESS

CITY

STATE
COUNTRY

BILLING ZIP CODE
NAME ON CARD

COMMENT

ATTACHMENT


PLEASE ATTACH TAX ID (Optional)

REFERENCES (Optional)

Signature



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Apply by E-File/Mail
To : Cybcar America
4930 Dacoma Street STE F
Houston TX 77092
Fax: (888)686-6227
Email: sales@Cybcar.us

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