Client Application and Service Agreement

The information provided is sensitive in nature.  To maintain compliance with the Fair Credit Reporting Act, and various other state laws and regulations, we must verify the legitimacy of all accounts.  We reserve the right to limit access to our services based upon verification of your business. 

Note:  This form must be completed by an officer of the company or other

  individual authorized to enter into a legal contract on behalf of your

  company.  If you have any questions, please call (978) 887-2071.

General Information

Company Name 

Business NAME your Company Listed                                                  (NAME, not the number)

with Business Directory

Business Telephone your company listed (Format: 999-999-9999)

with Business Directory

Fax Number 

Physical Address

Street Address                          (No Post Office Boxes)

City   State     Zip

Mailing Address

Address

City   State   Zip

Number of Employees

Please describe the nature of your business.  (Max of 250 characters)

SIC Code        (Format: 9999  Click for help.)

Federal Tax ID Number (Format: 99-9999999)

State ID Number

Business Structure

Date Formed                            (Format: 02/17/2001)

State of Formation

Dunn & Bradstreet Number

Internet Address

Administration / Primary User Contact Information

Name

E-mail Address

Name of Person Completing Form

Title of Person Completing Form

Certification: By choosing to submit this form electronically, I certify and agree that by entering/typing my name and information in the above spaces, I bind and legally obligate myself to the same extent as I would by signing my name on a printed version of this form.  I also certify that I have read, understand and accept the Agreements, Policies and Procedures set forth by CBSP, LLC.  I understand I must provide the required business documentation as listed and my application will not be processed until provided.

READ CAREFULLY BEFORE SUBMITTING: TERMS AND CONDITIONS: This agreement is made subject to the following terms, conditions & understandings: CBSP, LLC. will make reasonable efforts to locate the requested information and will make reasonable efforts to check the accuracy of any information provided. Since CBSP, LLC. does not prepare the underlying records its retrieves, it cannot guarantee the accuracy, timeliness or completeness of the information provided. CBSP, LLC. only guarantees that it will furnish all the information it has retrieved. CBSP, LLC. shall not be liable for any loss or injury resulting from the use of, failure to provide, or delay in receiving, such data. In the event that no information can be obtained on the subject matter(s) through our agreed efforts, CLIENT shall nevertheless be responsible for the payment of all fees agreed to be paid as specified above.

COMPLIANCE WITH THE FAIR CREDIT REPORTING ACT: CLIENT agrees that any requested reports or information which maybe covered by the FAIR CREDIT REPORTING ACT must be used in full compliance with the terms and intentions of that ACT. CLIENT recognizes and understands that the FAIR CREDIT REPORTING ACT provides that anyone "who knowingly and willfully obtains information on a consumer from a consumer reporting agency under false pretenses shall be fined not more that $5,000 or imprisoned not more than one year, or both."

GENERAL USE OF DATA: CLIENT agrees that the information supplied by CBSP, LLC. strictly for its own use, and that this information will NOT be used by CLIENT for any purposes prohibited by any governmental laws, statutes, ordinances, rules and/or regulations or with the intent to stalk, harm, slander or hurt another in anyway.

ANY FACSIMILE OR ELECTRONIC SUBMISSION of this agreement shall be deemed to be and shall serve as if it were the original agreement between the parties, providing all legal rights and remedies under the governing law of the STATE OF MASSACHUSETTS or other applicable governmental authorities. Client also agrees to pay any attorney's fees and court costs which we may incur in collecting any unpaid amount and agrees to pay any attorneys fees and court costs incurred by CBSP, LLC. in defending any lawsuit brought by client or client's representatives. Client agrees to give up right to local jurisdiction and understands and consents to any case arising from non-payment of a bill to be heard under Massachusetts jurisdiction.

   

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