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Shipping & Installation Address (if different than Billing) <br />Customer: <br />Department: <br />Street: <br />City: County: <br />State: Zip: <br />Tel: Fax: <br />E-mail: <br />Contact Name: <br />Mailing Address: Same as Billing <br /> Existing Customers Only: check box if Shipping & Install Address has changed. <br /> <br /> Customer Agreement <br /> <br />FP Mailing Solutions <br />140 N. Mitchell Ct, Ste 200 <br />Addison, IL 60101-5629 <br />Tel: (800) 341-6052 <br />www.fp-usa.com <br /> <br />CUSTOMER INFORMATION <br /> <br /> <br /> <br />RENTAL INFORMATION <br /> <br />Quantity Item # Item Description Monthly Rate Rental Billing Delivery (select one) <br /> Electronic Billing <br /> Paper Billing <br /> Rental Billing Frequency (select one) <br /> Annual Billing <br /> Semi-Annual <br /> Quarterly Billing <br /> <br />Term of Contract: months* Total Monthly Payment $ <br /> <br />Terms and Conditions: By signing below, I hereby acknowledge and agree that FP’s standard shipping rates and the additional terms and conditions available on the FP website at <br />www.fp-usa.com/terms-conditions are applicable to, and incorporated by reference into, this agreement. (If you do not have access to the internet, please contact FP directly at <br />800.341.6052 and we will provide you with a copy for your records.) * 36 Month Initial Term will apply unless otherwise indicated above. <br /> <br />CUSTOMER ACCEPTANCE (please complete all fields) <br />Customer Acceptance of Terms Dealer Information <br /> <br />Print Name of Authorized Representative: <br /> <br />Selling Dealer Name: <br /> <br />Dealer #: <br /> <br />Tel: <br /> <br />Address: <br /> <br />Tax ID: <br /> <br />State: <br /> <br />Tel: <br /> <br />Fax: <br />Authorized Signature: X <br />Sales Representative Name: <br /> <br />Date: Servicing Dealer Name: <br />Svc. Dealer #: <br /> <br />DEALER & INTERNAL USE ONLY <br /> <br />New Customer <br /> <br />Upgrade / Model Change <br />Renewal (no change of equipment) <br />Coterminous Add-On: ____________________________ <br />Change of Ownership <br />Existing Account No.: <br /> <br /> <br />Lease Company: <br />Major Account: <br />GSA / State Contract No.: <br />Master Billing Acct. No.: <br />Master Postage Acct. No.: <br /> <br /> <br />Promo Code: _____________________________________ <br />Package Code: ___________________________________ <br />Price or Terms Exception Approval (Form Attached) <br /> USPS® Location: (CPU Letter Attached) <br /> <br /> Tax-Exempt (Certificate Attached) <br /> <br /> <br /> <br /> <br />FM_MG_RENTAGR_12 Page 1 revised 4/3/2018 <br />Billing Address <br />Customer: <br />Department: <br />Street: <br />City: County: <br />State: Zip: <br />Tel: Fax: <br />E-mail: <br />Contact Name: <br />Deliver To: Dealer Customer Fulfilled from Dealer Inventory <br /> Existing Customers Only: check box if Billing Address has changed. <br />Note: If a payment option is not selected, FP <br />will default to Quarterly Paper Billing.