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Atlas Information Research, Inc. Payment Terms and Agreement

 YOU MUST FILL OUT THIS APPLICATION TO SET UP AN ACCOUNT WITH ATLAS INFORMATION RESEARCH, INC. There is a $35 account setup fee.
  Thank You Lic # FL A9700339
Instructions for selecting payment with a credit card or a faxed check.
CREDIT CARD - Fill in the blanks below. CHECK - Just attach a copy of a voided check to the indicated area of the lower portion of this form. We will create a bank draft using this information and submit it to your bank. The check number you specify below, or the number on the voided check, will be the one we use on all future orders unless you specify a different check number on your order. We will process your order the day it is received. If you need to make different arraignments, please call. Of course you will always receive a receipt showing your account payment by credit card or faxed check.
Check #________ CardType_______ Card #__________________________ Exp date: ___________
Name on card___________________________                              Security number ___________ Signature____________________________________                  (from rear of card)

All clients must completely fill out the box below--

I accept personal liability for any and all charges made by the below named company. I understand that if any of these debts are not paid in full within sixty (60) days from the invoice date that these debts may appear on my personal credit rating as well as that of the company. I also agree that by signing below I am authorizing the charge/debit indicated above and that this will be my method of payment for future orders unless agreed to differently in writing in the future. I further attest that I understand the Fair Credit Reporting Act (15 v.s.c.1681) and certify that requests will only be made for the following reasons and no other. Permissible purpose of reports: A consumer reporting agency may furnish a consumer report under the following circumstances and no other... (3) To a person which it has reason to believe - (A) intends to use the information in connection with a credit transaction involving the consumer on whom the information is to be furnished and involving the extension of credit to, or review or collection of an amount of the consumer: or (B) intends to use the information for employment purposes: or (C) intends to use the information in connection with the underwriting of insurance concerning the consumer: or (D) intends to use the information in connection with a determination of the consumer's eligibility for a license or other benefit granted by a governmental instrumentality required by law to consider an applicants financial responsibility or status. I also attest that all information obtained from Atlas Information Research, Inc. will be used for lawful purposes and hold Atlas Information Research, Inc. and/or it's suppliers harmless in any action arising from use or misuse or reliance on the information supplied. I understand that the fees are for searches, and not the actual information and that while Atlas Information Research, Inc. strives to obtain valid information, there are no warranties, expressed or implied, of information returned.
 
Company Name______________________________ FEIN (if incorporated)_____________ License#________________
Company Address_____________________________ City__________________ St___________ Zip_____________
Co Tel__________________ Fax_________________  CompanyEmail_______________________________________
Name of Officer Guaranteeing Payment________________________________________ Title_____________________
Social Security #___________________ Home Address_________________________________ City_______________
St____________ Zip_____________ Home Tel___________________ Email__________________________________
Signature X______________________________________________ Date________________

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Tape Voided Check Here (or on page 2 of this form) for faxed check payments. Checks are to be made out to Atlas Information Research, Inc. -Even if the Setup Fee is waived and you select Fax Checks, a blank or voided check is needed to setup the account.-

Fax to 863-647-4622 or Mail this completed form to:

Atlas Information Research, Inc., 4935 Southwind Drive, Mulberry, FL. 33860.

 

to the How To Order page.