ONLINE BROKER-VENDOR APPLICATION

Please complete the information in the following application to begin the process of becoming a TimePayment Vendor. If you wish to retain a  hardcopy for your records, you may do so by clicking the print form button prior to submitting this form for approval.


Broker Information (*indicates required information)

*Broker Name:  
*TPC Broker Number:  
*Broker Email:

Vendor Business Information

*Vendor Business Name: *Vendor Contact Name:
*Vendor Address: Position:
*Vendor City: *Vendor Phone:
*Vendor State: *Vendor Fax:
*Vendor Zip Code: *Vendor E-mail Address:
*Vendor Federal Tax ID: *Vendor Business Type:
*Vendor Yrs in Business: (Minimum 1 year in business required)  Receive e-mail from TPC?   Yes:   No:
Duns Number: If less than 2 yrs in Business, state past experience:
Business Alone: *No - Principal Information Required

Vendors Equipment Information
*Equipment Type:

Auth Distributor:

Manufacturer

 If Other Equip Type:

Comments:

Do you sell used equipment? Yes:  No:  Average Age of Used Equipment:

Vendors Principal Information (* required if not requesting business alone approval)

Principal Name:

SSN:

Address:

Phone:

City:

Title:

State:

Zip Code:

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 may be providing to TPC for the purpose of TPC funding the approved equipment lease, equipment rental, software rental monitoring service, 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, equipment renters, software renters, or, if applicable, subscribers of alarm monitoring services (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 @ 877-868-3800