*** N E W O P E N A C C O U N T A P P L I C A T I O N * * * Are you applying for a Business Account or Personal Account? To expedite the processing of your application please include copies of all documents that you reference in this application. Company/Personal Name: DBA Name (if applicable): Physical Address: City State Zip: Primary Phone #: Facsimile #: Cell / Mobile #: Alternate #: Primary Contact: Email quotes to: Are you Tax Exempt? No Yes Certificate # (supply a copy of your annual tax exempt certificate) Business is: Corporation Partnership Proprietorship LLC - Fed Tax EIN: If applying for a Personal Account we need your Driver s License # State of Issue: Type of Business: Years in Business: (Construction, event planner, non-profit, gov t, industrial, commercial, etc.) Do you require Purchase Order Numbers? Yes No Type of equipment needed: Will you be Renting Purchasing Service / Repairs from which Discount Equipment location(s) (check all that apply) From which location(s) Palm Beach Orlando Tampa DISCOUNT-EQUIPMENT.COM (check all that apply) How soon do you need the equipment: Immediately 1 Month 3 months 6 months or more? We do not mail invoices or statements; how do you want your invoices / statements sent to you? Email Fax Billing Address: Same as above or fill in the below if different. AP Contact Name: AP Business Phone: Ext: Business Fax: AP E-mail address: Street Address: City State Zip: DRS-NewAcctOpen-130307 Page 1 of 8
*** AUTHORIZED PURCHASERS (if applicable) *** Driver s License # State of Issue DRS-NewAcctOpen-130307 Page 2 of 8
* * * C R E D I T C A R D A U T H O R I Z A T I O N * * * Phone Number: Fax Number: Name, address and phone number of the card holder (same as the card s statement): Card Type Name: Master Card Visa Billing Address: Discover Amex City State Zip: Phone # Is this a Corporate Credit Card? Yes No Email: Card Number: Expiration: / CVV #: CVV Card Verification Value # Visa, MC, Discover - 3 digits located on back of Credit Card, American Express - 4 digits located on front of Credit Card I agree to any and all charges placed on the above referenced credit card for any and all sales, parts & service incurred at Discount Rental & Sales, Inc. and its subsidiaries. I agree to be held personally liable and further agree that if an attorney is retained to collect the charges, I will pay all reasonable attorneys fees and incurred costs. I agree to communicate without delay any matters pertaining to charges or disputes regarding the above Credit Card. In order to preserve my rights, I understand all complaints should be submitted in writing. Signature: Date: DRS-NewAcctOpen-130307 Page 3 of 8
*** I N S U R A N C E C E R T I F I C A T E S *** PLEASE CHARGE US FOR YOUR DAMAGE WAIVER FEE (14% OF RENTAL RATE). NO CERTIFICATE IS ENCLOSED. PLEASE DO NOT CHARGE DAMAGE WAIVER FEE (14% OF RENTAL RATE). ENCLOSED IS A COPY OF OUR INSURANCE CERTIFICATE FOR RENTAL EQUIPMENT SHOWING DISCOUNT RENTAL & SALES, INC. AS CERTIFICATE HOLDER AND LOSS PAYEE. *** WE MUST HAVE THE CERTIFICATE PRIOR TO RENTING *** Damage Waiver fees in the interim CANNOT be reversed. THE FOLLOWING INFORMATION IS REQUIRED ON ALL CERTIFICATES OF INSURANCE: 1. PHYSICAL DAMAGE COVERAGE/ALL RISK COVERAGE/AND REPLACEMENT COST FOR EQUIPMENT THAT IS RENTED, SUCH AS INLAND MARINE OR EQUIPMENT FLOATER POLICY, CONTRACTORS EQUIPMENT FLOATER POLICY, PROPERTY FLOATER POLICY. 2. DISCOUNT RENTAL & SALES, INC., NAMED AS ADDITIONAL INSURED LOSS PAYEE AND CERTIFICATE HOLDER. 3. MUST HAVE ADEQUATE LIABILITY COVERAGE AND SHOW POLICY COVERAGE DATES. 4. COVERAGE CAN BE LIMITED TO A SPECIFIC PIECE OF EQUIPMENT OR BLANKET COVERAGE FOR ALL RENTAL EQUIPMENT. Applicant s Signature: Date: DRS-NewAcctOpen-130307 Page 4 of 8
Desired Credit: $3,500 $7,000 $10,000 $25,000 $50,000 other $ I/We will be requesting Bank Financing through Discount Equipment. AUTHORIZED OFFICERS OF CORPORATION or PARTNERS or PROPRIETOR: Name: Title: Business Phone: Business Fax: E-mail address: Street Address: City State Zip: Driver s License # State of Issue: Social Security Number: Date of Birth: Name: Title: Business Phone: Business Fax: E-mail address: Street Address: City State Zip: Driver s License # State of Issue: Social Security Number: Date of Birth: Name: Title: Business Phone: Business Fax: E-mail address: Street Address: City State Zip: Driver s License # State of Issue: Social Security Number: Date of Birth: DRS-NewAcctOpen-130307 Page 5 of 8
* * * T R A D E / C R E D I T R E F E R E N C E S * * * Contact Name: Title: Business Phone: Business Fax: E-mail address: Street Address: City State Zip: Account #: Avg Monthly Payment / Credit Limit: Contact Name: Title: Business Phone: Business Fax: E-mail address: Street Address: City State Zip: Account #: Avg Monthly Payment / Credit Limit: Contact Name: Title: Business Phone: Business Fax: E-mail address: Street Address: City State Zip: Account #: Avg Monthly Payment / Credit Limit: Contact Name: Title: Business Phone: Business Fax: E-mail address: Street Address: City State Zip: Account #: Avg Monthly Payment / Credit Limit: Please sign as required & initial ALL pages, then fax completed application to: 561-209-6032 or scan it to: ar1@discount-equipment.com initials DRS-NewAcctOpen-130307 Page 6 of 8
* * * B A N K I N F O R M A T I O N * * * Name: Bank Officer: City/State: Account #: Phone #: Facsimile #: Email: The following authorization(s) shall apply to this application & subsequently for the purposes of update, renewal or extension of such credit & for reviewing or collecting the resulting account. A photo static or facsimile copy of this authorization shall be valid as the original. BUSINESS Credit Information: Authorization for Disclosure Applicant hereby authorizes the release of credit information to Discount Rental & Sales Inc. or its designee (and any affiliates, assignees or potential assignees thereof) from and source including credit bureau reporting agencies and applicant s bank. Hereby represent that all of the information contained in this credit application is true, correct and complete. Applicant agrees to be held liable for the debts and pay all collection costs, including attorneys fee and/or collection agency fees in addition to any additional fees on all delinquent accounts. Authorization for Disclosure: Applicant hereby authorizes Discount Rental or its designee (and any affiliates, assignees or potential assignees thereof) to execute and file any UCC financing statements in its name upon approval of the Application. PERSONAL Credit information: Authorization for Disclosure By signing below, the undersigned individual who is either a principal of the credit applicant or a personal guarantor of its obligations, provides written instruction Discount Rental & Sales Inc. or its designee (and any affiliates, assignees or potential assignees therefore) authorizing review of his/her personal credit profile from a national credit bureau. I agree to be held personally liable for the debts and pay all collection costs, including attorneys and/or collection agency fees in addition to any additional applicable fees on all delinquent accounts. By: By: Name: Name: Title: Date: Title: Date: ECOA NOTICE: the Federal Equal Credit Opportunity Act provides creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age (provided the applicant has the capacity to enter into a binding contract.) because all or part of the applicant s income derives from any public assistance or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act. The federal agency that administers compliance with this law is the Federal Trade Commission, Equal Credit Opportunity, Washington DC 20580. If your application for business credit is denied or conditionally approved, you have the right to a written statement of the specific reasons for the denial or the conditional approval. To obtain the statement, please contact Discount Rental & Sales Inc at 1014 S. Congress Avenue, West Palm Beach, FL 33406 within 60 days from the date you are notified of such denial or condition. We will send you a written statement of reasons for the denial within 30 days of receiving your request for the statement. DRS-NewAcctOpen-130307 Page 7 of 8
*** G U A R A N T Y *** In consideration of the extension of credit to the applicant named herein, the undersigned jointly severally and unconditionally guarantee and promise to pay all amounts now owing on which may hereinafter become owing by the applicant to Discount Rental and Sales, Inc. This is a continuing guaranty and obligations arising hereunder shall not be affected by any change in terms of indebtedness, the extension of credit beyond amounts specified herein, a change in the term of time for payment, a change in the form of indebtedness or the acceptance of security or collateral. Discount Rental and Sales, Inc. shall not be required to exhaust any remedies against applicant prior to exercising rights granted hereby. The undersigned hereby waives (1) notice of acceptance of this guaranty and of extension of credit by Discount Rental and Sales, Inc. to the applicant; (b) presentment and demand for paying of any indebtedness of the applicant; (c) protest and notice of dishonor or default to the undersigned with respect to any indebtedness of the applicant; (d) all other notices to which the undersigned might otherwise be entitled; (e) any demand for payment under this guaranty; (f) benefit of all exemptions and homestead laws; (g) all set-offs and counterclaims. This is a guaranty of payment and not of collection and the undersigned further waives any right to require that any action be brought against the applicant or any other person or to require that resort be had to any security. The undersigned agrees that, with or without notice or demand, the undersigned shall reimburse Discount Rental and Sales, Inc. to the extent that such reimbursement is not made by the applicant, for all expenses (including counsel fees) incurred by Discount Rental and Sales, Inc. in connection with any indebtedness of the applicant or the collection thereof, and will pay attorneys fees if this guaranty is placed with an attorney for enforcement of collection from the undersigned. The undersigned personal guarantor, recognizing that his or her individual credit history may be a necessary factor in the evaluation of this personal guarantee, hereby consents to and authorizes the use of a consumer credit report on the undersigned by Discount Rental and Sales, Inc. from time to time as may be needed in the credit evaluation process. If any provision or part of any provision of this guaranty is in conflict with any applicable statue or rule of law, then such provision, or part thereof, as the case may be, shall be deemed null and void to the extent that it may conflict therewith, but without invalidating the remaining provisions hereof or the remaining part of such. THE APPLICANT HEREBY WAIVES THE RIGHT TO A JURY TRIAL OF ANY DISPUTES WHICH MAY ARISE IN CONNECTION WITH THIS GUARANTY. The applicant further acknowledges and represents that any titles written near his/her signature is/are merely intended to clarify the individual s position with the customer and in no way is intended to limit or cancel the personal nature of this guaranty. Print Name: Signature: Date: DRS-NewAcctOpen-130307 Page 8 of 8