BRIVO SYSTEMS AUTHORIZED DEALER PROGRAM

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Reference #3Company Name: __________________________________________________________________Account Number: _________________________________________________________________Contact Name: ___________________________________________________________________Street Address: ___________________________________________________________________________________________________________________________________________________City: _______________________________ State: ________________Zip: ___________________Tel: ____________________________________ Fax: ____________________________________Product or Service Purchased: _______________________________________________________________________________________________________________________________________Brivo Systems, LLCProprietary & Confidential Page 8SAL-FRM-001-DealerApplicationForm.doc
PLEASE DO NOT CHARGE US TAX!We have a state tax resale number.Please attach a copy of your tax-exempt Certificate.Number: _____________________________ State:____________________WITHOUT A COPY OF YOUR TAX EXEMPT CERTIFICATEYOU WILL BE CHARGED SALES TAX!!NOTE: Brivo may at any time require that the Dealer provide a valid tax exemption certificate priorto fulfilling an order. If Brivo does not require an individual dealer to provide a tax exemptcertificate, taxes will be added by Brivo to the sales price where Brivo invoices the same to complywith law, and will be paid by Dealer.To the best of my knowledge everything I have stated in my application is true and correct.Yes! I want to become a Brivo Authorized Dealer.Signed: _________________________________Date: _____________________Name: __________________________________Title: ___________________________________Brivo Systems, LLCProprietary & Confidential Page 9SAL-FRM-001-DealerApplicationForm.doc
Page 1 and 2: ®4330 East West HighwaySuite 250Be
Page 3 and 4: DEALER PROFILE AND APPLICATIONPleas
Page 5 and 6: Describe your primary business focu
Page 7: I (we) authorize you to release nor

BRIVO SYSTEMS AUTHORIZED DEALER PROGRAM

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