How did you hear about us?

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Broker Information

Broker Legal Name

Applicant Information

Legal Business Name

Doing Business As (DBA)

Street 1

Street 2

City

State

Zip

Federal Tax ID

Business Type

Time in Business

Years/Months

MonthsYears

Annual Sales Volume

Primary Phone

Secondary Phone

Website

Receive emails from TimePayment?

YesNo

Duns Number

Equipment Information

Equipment Type

Do you sell used equipment?

YesNo

Authorized Distributor

Manufacturers

Comments

Primary Contact Information

First Name

Last Name

Phone

Would you like to submit Principal information for review?

YesNoThis information is often required for the evaluation of prefunding options when business credit has not been established. Program restrictions apply.

Principal Information

Is Prinicpal the same as Primary?

YesNo

First Name

Last Name

Phone

Street 1

Street 2

City

State

Zip

Social Security #

Authorization, Representations and Warranties

I hereby authorize and consent to TimePayment Corp. (hereinafter, 'TPC') and its affiliates, regarding both this 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 my company's bank account, which I may be providing to TPC for the purpose of TPC funding my company on approved equipment lease, equipment rental, software rental, monitoring service, or transactions.

As the applicant vendor seeking funding from TimePayment ('TPC') and seeking access to TPC's InfoHub portal (applicant vendor hereafter referred to as 'I,' 'my,' or 'my company'), I hereby certify that the information provided above is true and I agree that I, and any and all of my employees, sales representatives, and agents whom I may create an additional InfoHub user profile for ('Additional Users'), shall safeguard my InfoHub password and access to my account. I and my Additional Users further 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 and my Additional Users also agree to use the InfoHub system only for its stated purpose and that failure to do so may result in the immediate termination of my company's access to 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.

I agree to the above Authorizations, Representations, and Warranties

By typing my name and clicking submit, (1) I agree to all terms and conditions contained herein; (2) I agree to conduct this transaction electronically; and (3) I agree this typed representation of my name is my signature and consent.

Authorized Signers Name:

Authorized Signer's Title:

Date Signed:

AppType BVVBP FoundBroker YesNo BrokerCode	Address BrokerID AppID VendorID
Application Source