Reseller Application Document must be fully completed before an account is opened and pricing quoted. Description Of Business (Please type or print) _____________________________________________ ___________________________________________ Legal Business Name (as appears on business license) Also Officer’s/Principal Owner’s Name referred to as “Reseller” _____________________________________________ ___________________________________________ Business Trade Name (DBA) Title and E-mail Address _____________________________________________ ___________________________________________ Business Street Address (must be provided) President’s Name (if not principal owner) _____________________________________________ ___________________________________________ City, County, State and Zip Code (country if not USA) Title and E-mail Address _____________________________________________ ___________________________________________ Business Phone Authorized Purchaser(s) _____________________________________________ ___________________________________________ Business Fax Purchaser E-mail Address _____________________________________________ ___________________________________________ Business Web Site Address Accounts Payable Contact Name _____________________________________________ ___________________________________________ Ship To Street Address (if different from billing address) Accounts Payable E-mail Address _____________________________________________ ___________________________________________ Ship To City, State Zip Code (if different from billing address) Sales Manager _____________________________________________ ___________________________________________ Shipping Address (IF MORE THAN ONE, ATTACH LIST) Sales Manager E-mail Address Date business established:____________________Length of time at this address: Yrs.____ Mos.___ This company is a (check one): ı Sole Proprietorship ı Partnership ı Corporation: State___________ Type of corporation ı C ı S ı LLC (if LCC, enclose Articles of Organization) Is this a parent corporation or subsidiary? ı Parent ı Subsidiary If Subsidiary, who is Parent? __________________________________________________ Terms Requested: ı PREPAID (Credit Card, Wire transfer) ı C.O.D. (Cashier’s Check) ı C.O.D. COMPANY CHECK ı NET TERMS Credit Line Amount $______________ DUN & BRADSTREET #_______________________ *** Current Year-End Financial Statement Must Accompany Net Term Requests *** Customer agrees to notify Verso Technologies, Inc. of any changes in ownership of its business, billing address or shipping address as set forth herein by certified mail to the address listed below. Verso Technologies, Inc. Attn: Credit Department 400 Galleria Parkway, Suite 300 Atlanta, Georgia 30339 Phone: 678-589-3500 /Fax: 770-589-3750 Account Number Page 1 of 2 TRADE REFERENCES (Related industry purchases during past 12 months) Name Address Contact Name Telephone # Account # Name Address Contact Name Telephone # Account # Name Address Contact Name Telephone # Account # BANK REFERENCES (Please complete fully) Bank Name Account Officer’s Name Checking Account # Address (Street, City, State and Zip Code) Savings Account# Telephone # Fax # Loan Account # Bank Name Account Officer’s Name Checking Account # Address (Street, City, State and Zip Code) Savings Account# Telephone # Fax # Loan Account # AUTHORIZED SIGNATURE FOR BANK ACCOUNTS (To release bank information) THIS SECTION MUST BE COMPLETED IF RESELLER IS NOT INCORPORATED. Principal (Owner/Partner) Information (Use separate sheet if necessary to list 100% ownership) Owner/Partner Name % Ownership Social Security # Driver’s License # Address (Street, City, State and Zip Code) Telephone # Have you ever filed for bankruptcy? ı No ı Yes ı Personal ı Business Date Filed:_________ Status:_______ Owner/Partner Name % Ownership Social Security # Driver’s License # Address (Street, City, State and Zip Code) Telephone # Have you ever filed for bankruptcy? ı No ı Yes ı Personal ı Business Date Filed:_________ Status:_______ *** Current Year-End Financial Statement Must Accompany Net Term Requests *** Financial statement must include a balance sheet and income statement. Unaudited financial statements must be signed and dated by the company’s Owner/Officer. The statements time period must be indicated. This application and agreement is submitted by applicant to Verso Technologies, Inc. to obtain trade credit. Verso Technologies, Inc. reserves the right to decline credit to applicant and in the event credit is extended to the applicant, to change or revoke applicant’s credit limit on the basis of changes in Verso Technologies, Inc. standard sales terms and conditions in effect at the time of order. Any variance from those terms and conditions will be effective only if agreed to in writing by Telemate.Net prior to the time the product or services are ordered. Reseller agrees to make payment in full to Verso Technologies, Inc. for all amounts due according to Verso Technologies, Inc. invoices. Should the reseller default in any such payment(s), Verso Technologies, Inc. shall have the right, without notice to the reseller, to declare all invoice amounts due and payable in full. In the event Verso Technologies, Inc. should commence any action or actions, or otherwise seek to enforce this agreement against reseller, reseller agrees to pay reasonable attorney(s) fees, court costs and other expenses incurred by Verso Technologies, Inc., whether or not suit is filed. This agreement is strictly confidential and is not transferable or assignable without prior written consent of Verso Technologies, Inc. Reseller agrees that any change in liability for debts incurred to Verso Technologies, Inc. due to a change in customer’s form of business, shall not be effective as to Verso Technologies, Inc., until Verso Technologies Inc. receives notice by certified mail. Venue shall be Cobb County, Georgia as determined by Verso Technologies, Inc. ______________________________________________________ ____________________________________________ Officer/Owner Name (Please Print) Title _________________________________________ As of this __________ day of ___________, 20__________ Officer/Owner Signature Page 2 of 2