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 represent and warrant that I have obtained authorization from said Referral Program Dealer which allows TimePayment Corp. and its affiliates to conduct an investigation of the Referral Program Dealer's creditworthiness.

 

* 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 Direct.

 

* I hereby warrant and represent that: (a) When and if I receive a signed credit application from prospective lessee or lessees,  such credit applications authorize TPC to perform a credit check on those prospective lessee(s); and (b) to the best of my knowledge, the information provided in the credit application is not 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