Application for Service

AccuSource, Inc.
P.O. Box 1304
Hurst, TX 76053
Tel : (940) 627-4461 - Fax : (817) 887-5553
WWW : http://www.accu-source.com

This agreement is entered into this month of _____________________
day _____ 20 _____ by AccuSource, Inc. P.O. Box 1304
Hurst, TX 76053

Company Name : ______________________________________________________________

Physical Address : __________________________________________________________

City : _______________________________  State : _______  ZIP : ______________

Mailing Address : ___________________________________________________________

City : _______________________________  State : _______  ZIP : ______________

Telephone : (______) _______-___________  Fax : (______) _______-____________

Billing Email Address: _________________________________________

Service is to be furnished for a fee (as set out in price sheet) subject to the terms and conditions agreed to by User. The User agrees to abide by these terms and they are incorporated and made a part of this agreement.
User Number (Supplied by AS): _____________ Password : ____________________

Fill in the above and enter the password you desire (any group of numbers and/or letters up to 8 characters but not less than 5; alphabetic characters must be in UPPER CASE). Please mail this application and check or money order setup fee to (This can be faxed to expidite processing) : @ the above address. A USER NUMBER will be assigned to you, and you will be notified by phone, mail, or fax.

A user file will be opened and user number assigned by AccuSource. An AccuSource authorized representative will sign the original application, and a copy will be returned to you for your files.
 
User's Name : _____________________________________________

User's Title : ____________________________________________

User's Social Security Number : ________-_______-__________

User's Signature : ________________________________________

User's Email Address :_____________________________________

AccuSource, Inc : ___________________ Title : ____________________