New Agent Application 2013

1007 Mansell Rd. Ste. A

Roswell, GA 30076

Tel 678-290-1500 / 1-800-801-9080

Fax 800-921-4823

www.amerimex.com

NEW AGENT APPLICATION

Sales Representative:
Phone Number:

Business Name	DBA	Business Hours	Business Phone
Business Address	City	State	ZIP
Business Fax	Email address	Manager name	Phone
Owner Name	Owner Phone	Driver Lic	SSN
Administrator User	Password	Other user	Password

Note: Agent is responsible for all charges made using their log-in information. Agent Agrees to keep all customer information confidential. Agent agreed to allow AmeriMex Communications Corp. to charge their Credit Card or Debit Card or draft the following bank accounts for payment of money due AmeriMex. Nota: El Agente es responsable de todos los cargos realizados al utilizar los usuarios de acceso a su cuenta. El Agente esta de acuerdo en mantener la información del cliente confidencial. El Agente autoriza a AmeriMex Communications Corp. para realizar cargos a su tarjeta de crédito, débito ó realizar retiros del banco a continuación nombrado por pagos debidos a AmeriMex.

Credit Card

Credit Card Type:

Credit Card Number:

Expiration Date

CCS

Name as appear on the card:

Bank Account Information

Bank Name:		Routing Number:
Name on Bank Account:		Account Number:

Terms & Conditions

1- We will draft your account or charge your credit / debit card once a week.

2. If you Have any questions please contact us to 678-290-1500/800-801-9080 e-mail at billing@amerimex.com

State Sales Tax Registration Number __________

I am registered for sales and use tax purposes in the state of _______ and am purchasing these services for resale. By providing my sales tax registration number above and signing below, I assume full responsibility for any sales taxes, use taxes, or 911 fees due on my sales of all services sold as part of this agreement.

I authorize AmeriMex Communications Corp to verify my credit history and conduct a background check.

Name: ________________________

Signature: __________________________

Date: ______/_______/_______

AmeriMex keeps all agent information confidential and agrees not to disclose any agent information to an outside party.