apply.ur.com
Open in
urlscan Pro
63.241.148.130
Public Scan
URL:
https://apply.ur.com/apply
Submission Tags: falconsandbox
Submission: On December 29 via api from US — Scanned from DE
Submission Tags: falconsandbox
Submission: On December 29 via api from US — Scanned from DE
Form analysis 1 forms found in the DOM
Name: input_form — POST
<form method="POST" id="input_form" name="input_form" novalidate="novalidate">
<table style="background-color: #D7E4ED; width: 760px;" cellspacing="0" cellpadding="0" border="0">
<tbody>
<tr>
<td class="box-top"></td>
</tr>
<tr>
<td class="box-content">
<!-- table body start -->
<br>
<span id="idThemeBorder-mercury" class="mercury">
<table width="100%" cellpadding="8" style="margin-top:-15px" class="mercury">
<tbody>
<tr>
<td align="right" valign="top" width="50%">
<div class="mercury-plaintextheading">
<p>Have you worked with a URI employee? If so, please provide their name.</p>
</div>
<div class="fixedWidthElement">
<label for="CBURCT">Representative Name</label><input type="text" name="CBURCT" id="CBURCT" maxlength="20" class="optional" value="">
</div>
</td>
<td align="right" valign="top" width="50%" class="shorter">
<div class="fixedWidthElement">
<label for="CBSLRP">Sales Rep #</label><input type="text" name="CBSLRP" id="CBSLRP" maxlength="5" value="">
</div>
<div class="mercury-plaintextheading"><br></div>
<div class="fixedWidthElement">
</div>
</td>
</tr>
</tbody>
</table>
<table width="100%" cellpadding="8" style="margin-top:-15px" class="mercury">
<tbody>
<tr>
<td align="right" valign="top" width="50%">
<div class="mercury-subheading">Business Address</div>
<div class="fixedWidthElement">
<label for="CBANAM">* Business Name</label><input type="text" name="CBANAM" id="CBANAM" required="required" maxlength="30" value="">
</div>
<table class="radiotable">
<tbody>
<tr>
<td id="CBOWNR-label">
<label for="CBOWNR">* Occupancy Status</label>
</td>
<td class="fixedwidth">
<label><input type="radio" name="CBOWNR" id="CBOWNR" required="required" value="O">Own</label><label><input type="radio" name="CBOWNR" required="required" value="R">Rent</label>
</td>
</tr>
</tbody>
</table>
<div class="fixedWidthElement">
<label for="CBAAD1">* Address</label><input type="text" name="CBAAD1" id="CBAAD1" required="required" maxlength="30" value="">
</div>
<div class="fixedWidthElement">
<label for="CBAAD2">Address 2</label><input type="text" name="CBAAD2" id="CBAAD2" maxlength="30" value="">
</div>
<div class="fixedWidthElement">
<label for="CBACTY">* City</label><input type="text" name="CBACTY" id="CBACTY" required="required" maxlength="20" value="">
</div>
<div class="fixedWidthElement">
<label for="CBASTE">* State/Province</label><select name="CBASTE" id="CBASTE" required="required">
<option value=""></option>
<optgroup label="United States">
<option value="US-AL">Alabama</option>
<option value="US-AK">Alaska</option>
<option value="US-AZ">Arizona</option>
<option value="US-AR">Arkansas</option>
<option value="US-CA">California</option>
<option value="US-CO">Colorado</option>
<option value="US-CT">Connecticut</option>
<option value="US-DE">Delaware</option>
<option value="US-DC">District Of Columbia</option>
<option value="US-FL">Florida</option>
<option value="US-GA">Georgia</option>
<option value="US-HI">Hawaii</option>
<option value="US-ID">Idaho</option>
<option value="US-IL">Illinois</option>
<option value="US-IN">Indiana</option>
<option value="US-IA">Iowa</option>
<option value="US-KS">Kansas</option>
<option value="US-KY">Kentucky</option>
<option value="US-LA">Louisiana</option>
<option value="US-ME">Maine</option>
<option value="US-MD">Maryland</option>
<option value="US-MA">Massachusetts</option>
<option value="US-MI">Michigan</option>
<option value="US-MN">Minnesota</option>
<option value="US-MS">Mississippi</option>
<option value="US-MO">Missouri</option>
<option value="US-MT">Montana</option>
<option value="US-NE">Nebraska</option>
<option value="US-NV">Nevada</option>
<option value="US-NH">New Hampshire</option>
<option value="US-NJ">New Jersey</option>
<option value="US-NM">New Mexico</option>
<option value="US-NY">New York</option>
<option value="US-NC">North Carolina</option>
<option value="US-ND">North Dakota</option>
<option value="US-OH">Ohio</option>
<option value="US-OK">Oklahoma</option>
<option value="US-OR">Oregon</option>
<option value="US-PA">Pennsylvania</option>
<option value="US-PR">Puerto Rico</option>
<option value="US-RI">Rhode Island</option>
<option value="US-SC">South Carolina</option>
<option value="US-SD">South Dakota</option>
<option value="US-TN">Tennessee</option>
<option value="US-TX">Texas</option>
<option value="US-UT">Utah</option>
<option value="US-VT">Vermont</option>
<option value="US-VI">Virgin Islands</option>
<option value="US-VA">Virginia</option>
<option value="US-WA">Washington</option>
<option value="US-WV">West Virginia</option>
<option value="US-WI">Wisconsin</option>
<option value="US-WY">Wyoming</option>
</optgroup>
<optgroup label="Canada">
<option value="CA-AB">Alberta</option>
<option value="CA-BC">British Columbia</option>
<option value="CA-MB">Manitoba</option>
<option value="CA-NB">New Brunswick</option>
<option value="CA-NL">New Labrador</option>
<option value="CA-NT">Northwest Territories</option>
<option value="CA-NS">Nova Scotia</option>
<option value="CA-NU">Nunavut</option>
<option value="CA-ON">Ontario</option>
<option value="CA-PE">Prince Edward Island</option>
<option value="CA-QC">Quebec</option>
<option value="CA-SK">Saskatchewan</option>
<option value="CA-YT">Yukon</option>
</optgroup>
<optgroup label="Mexico">
<option value="MX-AG">Aguascalientes</option>
<option value="MX-BC">Baja California Norte</option>
<option value="MX-BS">Baja California Sur</option>
<option value="MX-CH">Chihuahua</option>
<option value="MX-CL">Colima</option>
<option value="MX-CM">Campeche</option>
<option value="MX-CO">Coahuila</option>
<option value="MX-CS">Chiapas</option>
<option value="MX-DF">Distrito Federal</option>
<option value="MX-DG">Durango</option>
<option value="MX-GR">Guerrero</option>
<option value="MX-GT">Guanajuato</option>
<option value="MX-HG">Hidalgo</option>
<option value="MX-JA">Jalisco</option>
<option value="MX-MI">Michoacan</option>
<option value="MX-MO">Morelos</option>
<option value="MX-NA">Nayarit</option>
<option value="MX-NL">Nuevo Leon</option>
<option value="MX-OA">Oaxaca</option>
<option value="MX-PU">Puebla</option>
<option value="MX-QR">Quintana Roo</option>
<option value="MX-QT">Queretaro</option>
<option value="MX-SI">Sinaloa</option>
<option value="MX-SL">San Luis Potosi</option>
<option value="MX-SO">Sonora</option>
<option value="MX-TB">Tabasco</option>
<option value="MX-TL">Tlaxcala</option>
<option value="MX-TM">Tamaulipas</option>
<option value="MX-VE">Veracruz</option>
<option value="MX-YU">Yucatan</option>
<option value="MX-ZA">Zacatecas</option>
</optgroup>
</select>
</div>
<div class="fixedWidthElement">
<label for="CBAZIP">* Zip/Postal Code</label><input type="text" name="CBAZIP" id="CBAZIP" required="required" maxlength="10" value="">
</div>
<div class="fixedWidthElement">
<label for="CBAACDAPHN">* Telephone Number</label><input type="text" name="CBAACDAPHN" id="CBAACDAPHN" required="required" value="">
</div>
<div class="fixedWidthElement">
<label for="CBAFXAAFXN">Fax Number</label><input type="text" name="CBAFXAAFXN" id="CBAFXAAFXN" value="">
</div>
</td>
<td align="right" valign="top" width="50%">
<div class="mercury-subheading">Account Payable Contact Information</div>
<div class="fixedWidthElement">
<label for="CBAPCT">* A/P Contact Name</label><input type="text" name="CBAPCT" id="CBAPCT" required="required" maxlength="30" value="">
</div>
<div class="fixedWidthElement">
<label for="CBAPEM">* Email Address</label><input type="text" name="CBAPEM" id="CBAPEM" required="required" maxlength="50" value="">
</div>
<div class="mercury-plaintextheading">
<div id="chkBoxId" style="margin-left:70px; padding-top:5px; padding-bottom:5px;">
<span class="chkBox">
<input id="copyAddress" name="copyAddress" value="Y" type="checkbox" style="width:auto">
</span>
<div class="chkBoxText" style="margin-left:25px; margin-right:0px;">
<label for="copyAddress" style="font-weight:normal; white-space:nowrap;">Billing Address same as Business Address</label>
</div>
</div>
</div>
<div class="fixedWidthElement">
<label for="CBBAD1">* Billing Address</label><input type="text" name="CBBAD1" id="CBBAD1" required="required" maxlength="30" value="">
</div>
<div class="fixedWidthElement">
<label for="CBBCTY">* City</label><input type="text" name="CBBCTY" id="CBBCTY" required="required" maxlength="20" value="">
</div>
<div class="fixedWidthElement">
<label for="CBBSTE">* State/Province</label><select name="CBBSTE" id="CBBSTE" required="required">
<option value=""></option>
<optgroup label="United States">
<option value="US-AL">Alabama</option>
<option value="US-AK">Alaska</option>
<option value="US-AZ">Arizona</option>
<option value="US-AR">Arkansas</option>
<option value="US-CA">California</option>
<option value="US-CO">Colorado</option>
<option value="US-CT">Connecticut</option>
<option value="US-DE">Delaware</option>
<option value="US-DC">District Of Columbia</option>
<option value="US-FL">Florida</option>
<option value="US-GA">Georgia</option>
<option value="US-HI">Hawaii</option>
<option value="US-ID">Idaho</option>
<option value="US-IL">Illinois</option>
<option value="US-IN">Indiana</option>
<option value="US-IA">Iowa</option>
<option value="US-KS">Kansas</option>
<option value="US-KY">Kentucky</option>
<option value="US-LA">Louisiana</option>
<option value="US-ME">Maine</option>
<option value="US-MD">Maryland</option>
<option value="US-MA">Massachusetts</option>
<option value="US-MI">Michigan</option>
<option value="US-MN">Minnesota</option>
<option value="US-MS">Mississippi</option>
<option value="US-MO">Missouri</option>
<option value="US-MT">Montana</option>
<option value="US-NE">Nebraska</option>
<option value="US-NV">Nevada</option>
<option value="US-NH">New Hampshire</option>
<option value="US-NJ">New Jersey</option>
<option value="US-NM">New Mexico</option>
<option value="US-NY">New York</option>
<option value="US-NC">North Carolina</option>
<option value="US-ND">North Dakota</option>
<option value="US-OH">Ohio</option>
<option value="US-OK">Oklahoma</option>
<option value="US-OR">Oregon</option>
<option value="US-PA">Pennsylvania</option>
<option value="US-PR">Puerto Rico</option>
<option value="US-RI">Rhode Island</option>
<option value="US-SC">South Carolina</option>
<option value="US-SD">South Dakota</option>
<option value="US-TN">Tennessee</option>
<option value="US-TX">Texas</option>
<option value="US-UT">Utah</option>
<option value="US-VT">Vermont</option>
<option value="US-VI">Virgin Islands</option>
<option value="US-VA">Virginia</option>
<option value="US-WA">Washington</option>
<option value="US-WV">West Virginia</option>
<option value="US-WI">Wisconsin</option>
<option value="US-WY">Wyoming</option>
</optgroup>
<optgroup label="Canada">
<option value="CA-AB">Alberta</option>
<option value="CA-BC">British Columbia</option>
<option value="CA-MB">Manitoba</option>
<option value="CA-NB">New Brunswick</option>
<option value="CA-NL">New Labrador</option>
<option value="CA-NT">Northwest Territories</option>
<option value="CA-NS">Nova Scotia</option>
<option value="CA-NU">Nunavut</option>
<option value="CA-ON">Ontario</option>
<option value="CA-PE">Prince Edward Island</option>
<option value="CA-QC">Quebec</option>
<option value="CA-SK">Saskatchewan</option>
<option value="CA-YT">Yukon</option>
</optgroup>
<optgroup label="Mexico">
<option value="MX-AG">Aguascalientes</option>
<option value="MX-BC">Baja California Norte</option>
<option value="MX-BS">Baja California Sur</option>
<option value="MX-CH">Chihuahua</option>
<option value="MX-CL">Colima</option>
<option value="MX-CM">Campeche</option>
<option value="MX-CO">Coahuila</option>
<option value="MX-CS">Chiapas</option>
<option value="MX-DF">Distrito Federal</option>
<option value="MX-DG">Durango</option>
<option value="MX-GR">Guerrero</option>
<option value="MX-GT">Guanajuato</option>
<option value="MX-HG">Hidalgo</option>
<option value="MX-JA">Jalisco</option>
<option value="MX-MI">Michoacan</option>
<option value="MX-MO">Morelos</option>
<option value="MX-NA">Nayarit</option>
<option value="MX-NL">Nuevo Leon</option>
<option value="MX-OA">Oaxaca</option>
<option value="MX-PU">Puebla</option>
<option value="MX-QR">Quintana Roo</option>
<option value="MX-QT">Queretaro</option>
<option value="MX-SI">Sinaloa</option>
<option value="MX-SL">San Luis Potosi</option>
<option value="MX-SO">Sonora</option>
<option value="MX-TB">Tabasco</option>
<option value="MX-TL">Tlaxcala</option>
<option value="MX-TM">Tamaulipas</option>
<option value="MX-VE">Veracruz</option>
<option value="MX-YU">Yucatan</option>
<option value="MX-ZA">Zacatecas</option>
</optgroup>
</select>
</div>
<div class="fixedWidthElement">
<label for="CBBZIP">* Zip/Postal Code</label><input type="text" name="CBBZIP" id="CBBZIP" required="required" maxlength="10" value="">
</div>
</td>
</tr>
</tbody>
</table>
<div class="mercury-heading">Business Information</div>
<table width="100%" cellpadding="8" style="margin-top:-15px" class="mercury">
<tbody>
<tr>
<td align="right" valign="top" width="50%" class="short">
<div class="fixedWidthElement">
<label for="CBESTB">* Date Established M/D/YYYY</label><input type="text" name="CBESTB" id="CBESTB" required="required" maxlength="10" value="" class="hasDatepicker">
</div>
<div class="fixedWidthElement">
<label for="CBTMBdollar">* Anticipated Monthly Charge Amt.</label><input type="text" name="CBTMBdollar" id="CBTMBdollar" required="required" maxlength="9" value="">
</div>
<div class="fixedWidthElement">
<label for="CBBSOF">* Nature of Business</label><input type="text" name="CBBSOF" id="CBBSOF" required="required" maxlength="20" value="">
</div>
<div class="fixedWidthElement">
<label for="CBLICpound">* Contractor License Number</label><input type="text" name="CBLICpound" id="CBLICpound" maxlength="20" value="">
</div>
</td>
<td align="right" valign="top" width="50%">
<table class="radiotable">
<tbody>
<tr>
<td id="CBTYPE-label">
<label for="CBTYPE">* Type of Business</label>
</td>
<td class="fixedwidth">
<label><input type="radio" name="CBTYPE" id="CBTYPE" required="required" value="C">Corporation</label><br><label><input type="radio" name="CBTYPE" required="required" value="P">Partnership</label><br><label><input
type="radio" name="CBTYPE" required="required" value="S">Sole Proprietor</label>
</td>
</tr>
</tbody>
</table>
<div class="fixedWidthElement">
<label for="CBTAX">* Tax Exempt Status?</label><select name="CBTAX" id="CBTAX" required="required">
<option value=""></option>
<option value="Y">No</option>
<option value="N">Yes, (Certificate Required)</option>
</select>
</div>
<div id="idCBTAXConditional" class="conditional" style="display:none">
<div class="fixedWidthElement">
<label for="CBFIDpound">Tax ID #</label><input type="text" name="CBFIDpound" id="CBFIDpound" value="">
</div>
<div class="fixedWidthElement">
<label for="CBRSAL">or Resale #</label><input type="text" name="CBRSAL" id="CBRSAL" maxlength="20" value="">
</div>
</div>
</td>
</tr>
</tbody>
</table>
<div class="mercury-heading">Owners (If Applicant is Sole Owner or Partnership) or Officers (If Corporation)</div>
<table width="100%" cellpadding="8" style="margin-top:-15px" class="mercury">
<tbody>
<tr>
<td align="right" valign="top" width="50%">
<div class="fixedWidthElement">
<label for="CBONM1">* Owner/Officer #1 Name</label><input type="text" name="CBONM1" id="CBONM1" required="required" maxlength="30" value="">
</div>
<div class="fixedWidthElement">
<label for="CBTIT1">* Title</label><input type="text" name="CBTIT1" id="CBTIT1" required="required" maxlength="30" value="">
</div>
<div class="fixedWidthElement">
<label for="CBSSN1">SSN / SIN</label><input type="text" name="CBSSN1" id="CBSSN1" maxlength="12" value="">
</div>
<div class="fixedWidthElement">
<label for="CBADR1">* Address</label><input type="text" name="CBADR1" id="CBADR1" required="required" maxlength="30" value="">
</div>
<div class="fixedWidthElement">
<label for="CBCTY1">* City</label><input type="text" name="CBCTY1" id="CBCTY1" required="required" maxlength="15" value="">
</div>
<div class="fixedWidthElement">
<label for="CBSTA1">* State/Province</label><select name="CBSTA1" id="CBSTA1" required="required">
<option value=""></option>
<optgroup label="United States">
<option value="US-AL">Alabama</option>
<option value="US-AK">Alaska</option>
<option value="US-AZ">Arizona</option>
<option value="US-AR">Arkansas</option>
<option value="US-CA">California</option>
<option value="US-CO">Colorado</option>
<option value="US-CT">Connecticut</option>
<option value="US-DE">Delaware</option>
<option value="US-DC">District Of Columbia</option>
<option value="US-FL">Florida</option>
<option value="US-GA">Georgia</option>
<option value="US-HI">Hawaii</option>
<option value="US-ID">Idaho</option>
<option value="US-IL">Illinois</option>
<option value="US-IN">Indiana</option>
<option value="US-IA">Iowa</option>
<option value="US-KS">Kansas</option>
<option value="US-KY">Kentucky</option>
<option value="US-LA">Louisiana</option>
<option value="US-ME">Maine</option>
<option value="US-MD">Maryland</option>
<option value="US-MA">Massachusetts</option>
<option value="US-MI">Michigan</option>
<option value="US-MN">Minnesota</option>
<option value="US-MS">Mississippi</option>
<option value="US-MO">Missouri</option>
<option value="US-MT">Montana</option>
<option value="US-NE">Nebraska</option>
<option value="US-NV">Nevada</option>
<option value="US-NH">New Hampshire</option>
<option value="US-NJ">New Jersey</option>
<option value="US-NM">New Mexico</option>
<option value="US-NY">New York</option>
<option value="US-NC">North Carolina</option>
<option value="US-ND">North Dakota</option>
<option value="US-OH">Ohio</option>
<option value="US-OK">Oklahoma</option>
<option value="US-OR">Oregon</option>
<option value="US-PA">Pennsylvania</option>
<option value="US-PR">Puerto Rico</option>
<option value="US-RI">Rhode Island</option>
<option value="US-SC">South Carolina</option>
<option value="US-SD">South Dakota</option>
<option value="US-TN">Tennessee</option>
<option value="US-TX">Texas</option>
<option value="US-UT">Utah</option>
<option value="US-VT">Vermont</option>
<option value="US-VI">Virgin Islands</option>
<option value="US-VA">Virginia</option>
<option value="US-WA">Washington</option>
<option value="US-WV">West Virginia</option>
<option value="US-WI">Wisconsin</option>
<option value="US-WY">Wyoming</option>
</optgroup>
<optgroup label="Canada">
<option value="CA-AB">Alberta</option>
<option value="CA-BC">British Columbia</option>
<option value="CA-MB">Manitoba</option>
<option value="CA-NB">New Brunswick</option>
<option value="CA-NL">New Labrador</option>
<option value="CA-NT">Northwest Territories</option>
<option value="CA-NS">Nova Scotia</option>
<option value="CA-NU">Nunavut</option>
<option value="CA-ON">Ontario</option>
<option value="CA-PE">Prince Edward Island</option>
<option value="CA-QC">Quebec</option>
<option value="CA-SK">Saskatchewan</option>
<option value="CA-YT">Yukon</option>
</optgroup>
<optgroup label="Mexico">
<option value="MX-AG">Aguascalientes</option>
<option value="MX-BC">Baja California Norte</option>
<option value="MX-BS">Baja California Sur</option>
<option value="MX-CH">Chihuahua</option>
<option value="MX-CL">Colima</option>
<option value="MX-CM">Campeche</option>
<option value="MX-CO">Coahuila</option>
<option value="MX-CS">Chiapas</option>
<option value="MX-DF">Distrito Federal</option>
<option value="MX-DG">Durango</option>
<option value="MX-GR">Guerrero</option>
<option value="MX-GT">Guanajuato</option>
<option value="MX-HG">Hidalgo</option>
<option value="MX-JA">Jalisco</option>
<option value="MX-MI">Michoacan</option>
<option value="MX-MO">Morelos</option>
<option value="MX-NA">Nayarit</option>
<option value="MX-NL">Nuevo Leon</option>
<option value="MX-OA">Oaxaca</option>
<option value="MX-PU">Puebla</option>
<option value="MX-QR">Quintana Roo</option>
<option value="MX-QT">Queretaro</option>
<option value="MX-SI">Sinaloa</option>
<option value="MX-SL">San Luis Potosi</option>
<option value="MX-SO">Sonora</option>
<option value="MX-TB">Tabasco</option>
<option value="MX-TL">Tlaxcala</option>
<option value="MX-TM">Tamaulipas</option>
<option value="MX-VE">Veracruz</option>
<option value="MX-YU">Yucatan</option>
<option value="MX-ZA">Zacatecas</option>
</optgroup>
</select>
</div>
<div class="fixedWidthElement">
<label for="CBZIP1">* Zip/Postal Code</label><input type="text" name="CBZIP1" id="CBZIP1" required="required" maxlength="10" value="">
</div>
<div class="fixedWidthElement">
<label for="CBACD1PHN1">* Telephone Number</label><input type="text" name="CBACD1PHN1" id="CBACD1PHN1" required="required" value="">
</div>
</td>
<td align="right" valign="top" width="50%">
<div class="fixedWidthElement">
<label for="CBONM2">Owner/Officer #2 Name</label><input type="text" name="CBONM2" id="CBONM2" maxlength="30" value="">
</div>
<div class="fixedWidthElement">
<label for="CBTIT2">Title</label><input type="text" name="CBTIT2" id="CBTIT2" maxlength="30" value="">
</div>
<div class="fixedWidthElement">
<label for="CBSSN2">SSN / SIN</label><input type="text" name="CBSSN2" id="CBSSN2" maxlength="12" value="">
</div>
<div class="fixedWidthElement">
<label for="CBADR2">Address</label><input type="text" name="CBADR2" id="CBADR2" maxlength="30" value="">
</div>
<div class="fixedWidthElement">
<label for="CBCTY2">City</label><input type="text" name="CBCTY2" id="CBCTY2" maxlength="15" value="">
</div>
<div class="fixedWidthElement">
<label for="CBSTA2">State/Province</label><select name="CBSTA2" id="CBSTA2">
<option value=""></option>
<optgroup label="United States">
<option value="US-AL">Alabama</option>
<option value="US-AK">Alaska</option>
<option value="US-AZ">Arizona</option>
<option value="US-AR">Arkansas</option>
<option value="US-CA">California</option>
<option value="US-CO">Colorado</option>
<option value="US-CT">Connecticut</option>
<option value="US-DE">Delaware</option>
<option value="US-DC">District Of Columbia</option>
<option value="US-FL">Florida</option>
<option value="US-GA">Georgia</option>
<option value="US-HI">Hawaii</option>
<option value="US-ID">Idaho</option>
<option value="US-IL">Illinois</option>
<option value="US-IN">Indiana</option>
<option value="US-IA">Iowa</option>
<option value="US-KS">Kansas</option>
<option value="US-KY">Kentucky</option>
<option value="US-LA">Louisiana</option>
<option value="US-ME">Maine</option>
<option value="US-MD">Maryland</option>
<option value="US-MA">Massachusetts</option>
<option value="US-MI">Michigan</option>
<option value="US-MN">Minnesota</option>
<option value="US-MS">Mississippi</option>
<option value="US-MO">Missouri</option>
<option value="US-MT">Montana</option>
<option value="US-NE">Nebraska</option>
<option value="US-NV">Nevada</option>
<option value="US-NH">New Hampshire</option>
<option value="US-NJ">New Jersey</option>
<option value="US-NM">New Mexico</option>
<option value="US-NY">New York</option>
<option value="US-NC">North Carolina</option>
<option value="US-ND">North Dakota</option>
<option value="US-OH">Ohio</option>
<option value="US-OK">Oklahoma</option>
<option value="US-OR">Oregon</option>
<option value="US-PA">Pennsylvania</option>
<option value="US-PR">Puerto Rico</option>
<option value="US-RI">Rhode Island</option>
<option value="US-SC">South Carolina</option>
<option value="US-SD">South Dakota</option>
<option value="US-TN">Tennessee</option>
<option value="US-TX">Texas</option>
<option value="US-UT">Utah</option>
<option value="US-VT">Vermont</option>
<option value="US-VI">Virgin Islands</option>
<option value="US-VA">Virginia</option>
<option value="US-WA">Washington</option>
<option value="US-WV">West Virginia</option>
<option value="US-WI">Wisconsin</option>
<option value="US-WY">Wyoming</option>
</optgroup>
<optgroup label="Canada">
<option value="CA-AB">Alberta</option>
<option value="CA-BC">British Columbia</option>
<option value="CA-MB">Manitoba</option>
<option value="CA-NB">New Brunswick</option>
<option value="CA-NL">New Labrador</option>
<option value="CA-NT">Northwest Territories</option>
<option value="CA-NS">Nova Scotia</option>
<option value="CA-NU">Nunavut</option>
<option value="CA-ON">Ontario</option>
<option value="CA-PE">Prince Edward Island</option>
<option value="CA-QC">Quebec</option>
<option value="CA-SK">Saskatchewan</option>
<option value="CA-YT">Yukon</option>
</optgroup>
<optgroup label="Mexico">
<option value="MX-AG">Aguascalientes</option>
<option value="MX-BC">Baja California Norte</option>
<option value="MX-BS">Baja California Sur</option>
<option value="MX-CH">Chihuahua</option>
<option value="MX-CL">Colima</option>
<option value="MX-CM">Campeche</option>
<option value="MX-CO">Coahuila</option>
<option value="MX-CS">Chiapas</option>
<option value="MX-DF">Distrito Federal</option>
<option value="MX-DG">Durango</option>
<option value="MX-GR">Guerrero</option>
<option value="MX-GT">Guanajuato</option>
<option value="MX-HG">Hidalgo</option>
<option value="MX-JA">Jalisco</option>
<option value="MX-MI">Michoacan</option>
<option value="MX-MO">Morelos</option>
<option value="MX-NA">Nayarit</option>
<option value="MX-NL">Nuevo Leon</option>
<option value="MX-OA">Oaxaca</option>
<option value="MX-PU">Puebla</option>
<option value="MX-QR">Quintana Roo</option>
<option value="MX-QT">Queretaro</option>
<option value="MX-SI">Sinaloa</option>
<option value="MX-SL">San Luis Potosi</option>
<option value="MX-SO">Sonora</option>
<option value="MX-TB">Tabasco</option>
<option value="MX-TL">Tlaxcala</option>
<option value="MX-TM">Tamaulipas</option>
<option value="MX-VE">Veracruz</option>
<option value="MX-YU">Yucatan</option>
<option value="MX-ZA">Zacatecas</option>
</optgroup>
</select>
</div>
<div class="fixedWidthElement">
<label for="CBZIP2">Zip/Postal Code</label><input type="text" name="CBZIP2" id="CBZIP2" maxlength="10" value="">
</div>
<div class="fixedWidthElement">
<label for="CBACD2PHN2">Telephone Number</label><input type="text" name="CBACD2PHN2" id="CBACD2PHN2" value="">
</div>
</td>
</tr>
</tbody>
</table>
<div class="mercury-heading">Please supply the following information to help us serve your accounts</div>
<table width="100%" cellpadding="8" style="margin-top:-15px" class="mercury">
<tbody>
<tr>
<td align="right" valign="top" width="50%" class="YN">
<table class="radiotable">
<tbody>
<tr>
<td id="CBPONI-label">
<label for="CBPONI">* 1. Do you require a purchase order number on each invoice?<br> If Yes, equipment will not be released unless provided.</label>
</td>
<td class="fixedwidth">
<label><input type="radio" name="CBPONI" id="CBPONI" required="required" value="Y">Yes</label><label><input type="radio" name="CBPONI" required="required" value="N">No</label>
</td>
</tr>
</tbody>
</table>
<table class="radiotable">
<tbody>
<tr>
<td id="CBSREQ-label">
<label for="CBSREQ">* 2. Do you require a monthly statement?</label>
</td>
<td class="fixedwidth">
<label><input type="radio" name="CBSREQ" id="CBSREQ" required="required" value="Y">Yes</label><label><input type="radio" name="CBSREQ" required="required" value="N">No</label>
</td>
</tr>
</tbody>
</table>
<table class="radiotable">
<tbody>
<tr>
<td id="CBEMYN-label">
<label for="CBEMYN">* 3. We elect to 'Go Green' by receiving invoices and statements via email.</label>
</td>
<td class="fixedwidth">
<label><input type="radio" name="CBEMYN" id="CBEMYN" required="required" value="Y">Yes</label><label><input type="radio" name="CBEMYN" required="required" value="N">No</label>
</td>
</tr>
</tbody>
</table>
<div class="mercury-plaintextheading">
<span class="optOut">* 4. Rental Protection Plan (RPP) will be charged on every contract. To opt out of this charge, <br> please send a Certificate of Insurance to
<a href="mailto:rppoptout@ur.com" style="text-decoration: underline">rppoptout@ur.com</a></span>
</div>
<div class="mercury-plaintextheading">
<br>
</div>
<table class="radiotable">
<tbody>
<tr>
<td id="CBPREV-label">
<label for="CBPREV">* 5. Have you ever had a previous account with United Rentals or its subsidiaries?</label>
</td>
<td class="fixedwidth">
<label><input type="radio" name="CBPREV" id="CBPREV" required="required" value="Y">Yes</label><label><input type="radio" name="CBPREV" required="required" value="N">No</label>
</td>
</tr>
</tbody>
</table>
<div class="fixedWidthElement">
<label for="CBAPApound">If Yes, Account Number</label><input type="text" name="CBAPApound" id="CBAPApound" maxlength="15" value="">
</div>
<table class="radiotable">
<tbody>
<tr>
<td id="CBUDF3-label">
<label for="CBUDF3">* 6. Will you provide a certificate of insurance evidencing general liability coverage<br> and property coverage naming United Rentals as loss payee and additional
insured?</label>
</td>
<td class="fixedwidth">
<label><input type="radio" name="CBUDF3" id="CBUDF3" required="required" value="Y">Yes</label><label><input type="radio" name="CBUDF3" required="required" value="N">No</label>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
</tbody>
</table>
<div class="mercury-heading">Open Account Credit Terms</div>
<table width="100%" cellpadding="8" style="margin-top:-15px" class="mercury">
<tbody>
<tr>
<td align="right" valign="top" width="50%" class="YN">
<div class="mercury-plaintextheading">
<ol>
<li>Each invoice is due upon receipt. </li>
<li>If equipment is rented for more than 4 weeks, periodic unsigned invoices will be issued for rental charge due. All such invoices are due upon receipt. </li>
<li>At the discretion of United Rentals, any account with a delinquent balance may be placed on a cash basis any time, and the equipment picked up without notice. </li>
<li>United Rentals files preliminary lien notices and mechanics liens whenever necessary or required by law. This is a company policy, and is not a reflection of your credit standing. </li>
<li>For each delinquent account, customer agrees to pay a monthly service charge equal to 2% of the past due balance or the maximum service charge permitted by law in the state where the contract is signed. </li>
<li>Customer agrees to pay all reasonable attorney fees, collection costs, and court costs incurred by United Rentals in enforcing these terms and conditions. </li>
<li>Customer authorizes United Rentals to obtain credit reports, trade reports, and bank references for the purpose of determining the extension or continuation of credit to customer. </li>
<li>Customer agrees to the terms and conditions as stated on each and every United Rental's invoice. </li>
</ol>
<p> The undersigned warrants that all information is correct, has read, accepted and agrees to be bound by all of the terms set forth in this document and in each rental contract entered into by the undersigned or his agents. It
is understood and agreed that the undersigned specifically consents to United Rentals investigating of the applicant's credit history and may utilize credit reporting services for information on the undersigned. Facsimile
copies will be accepted as originals. </p>
<p> The Federal Equal Credit Opportunity Act/regulation B prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age (provided the applicant
has the capacity to enter into a binding contract); because all or part of the applicant's income derives from any public assistance program; or because the applicant has, in good faith, exercised any right under the Consumer
Credit Protection Act. The federal agency that administers compliance with the law concerning this credit is the Federal Trade Commission, Division of Credit Practices, 6TH and Pennsylvania Avenue, NW Washington, D.C. 20580.
</p>
<p> In the event Credit Applicant enters into an agreement with United Rentals to purchase used rental or transportation equipment, Credit Applicant is hereby notified that United Rentals has assigned its rights (but not its
obligations) in such agreement to United Rentals Exchange, LLC., a qualified intermediary, as part of a Section 1031 like-kind exchange program. </p>
<div id="chkBoxId">
<span class="chkBox">
<input type="hidden" name="authorize_sig2" value="0"><input type="checkbox" name="authorize_sig2" id="authorize_sig2" required="required" style="width:auto" value="Y"> </span>
<div class="chkBoxText">
<label for="authorize_sig2">By checking this box, I authorize my signature and hereby agree to the Credit Terms and conditions listed on this application for a new credit account; in addition, I hereby authorize the bank
named above to release information requested for the purpose of obtaining and/or reviewing credit.</label>
</div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
<table width="100%" cellpadding="8" style="margin-top:-15px" class="mercury">
<tbody>
<tr>
<td align="right" valign="top" width="50%">
<div class="fixedWidthElement">
<label for="CBONM3">* Print Name</label><input type="text" name="CBONM3" id="CBONM3" required="required" maxlength="30" value="">
</div>
</td>
<td align="right" valign="top" width="50%">
<div class="mercury-plaintextheading">
<div style="margin-top:7px">
<label>Date Signed</label> 12/29/21
</div>
</div>
</td>
</tr>
</tbody>
</table>
<div class="mercury-heading">Consent to obtain consumer credit report</div>
<table width="100%" cellpadding="8" style="margin-top:-15px" class="mercury">
<tbody>
<tr>
<td align="right" valign="top" width="50%" class="YN">
<div class="mercury-plaintextheading">
<p>The undersigned individual who is either a principal of the credit applicant or a sole proprietorship of the credit applicant, recognizing that his or her individual credit history may be a factor in the evaluation of the
credit history of the applicant, hereby consents to and authorizes the use of a consumer credit report on the undersigned by the above named business credit grantor, from time to time as may be needed, in the credit evaluation
process.</p>
</div>
</td>
</tr>
</tbody>
</table>
<div class="mercury-heading">Continuing personal guarantee</div>
<table width="100%" cellpadding="8" style="margin-top:-15px" class="mercury">
<tbody>
<tr>
<td align="right" valign="top" width="50%" class="YN">
<div class="mercury-plaintextheading">
<p>The undersigned hereby unconditionally guarantee(s) the full and prompt payment to United Rentals when due all indebtedness, obligations, and liabilities of the customer named in the Credit Application, including all amounts
now owing and arising in the future, and including any interest, attorney fees, and collection and court costs. The undersigned agrees to be personally bound by all credit terms of this Credit Application. This guarantee shall
continue in force until notice in writing sent by certified mail, return receipt requested, is received by United Rentals. This notice shall specify the date of termination, not to be less than seven (7) days after the notice
and shall not affect any charges for transactions with the customer that were entered into prior to the termination date.</p>
<p>The undersigned personal guarantor, recognizing that his or her individual credit history may be a necessary factor in the evaluation of this personal guarantee, hereby consents to and authorizes the use of a consumer credit
report on the undersigned, by the above named business credit grantor, from time to time as may be needed, in the credit evaluation process.</p>
<div id="chkBoxId">
<span class="chkBox">
<input type="hidden" name="authorize_sig" value="0"><input type="checkbox" name="authorize_sig" id="authorize_sig" style="width:auto" value="Y"> </span>
<div class="chkBoxText">
<label for="authorize_sig">By checking this box, I authorize my signature and hereby agree to all the terms and conditions listed on this application for a new credit account, in addition to those listed in the "Continuing
personal guarantee" section of this form.</label>
</div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
<table width="100%" cellpadding="8" style="margin-top:-15px" class="mercury">
<tbody>
<tr>
<td align="right" valign="top" width="50%">
<div class="fixedWidthElement">
<label for="CBTIT3">Print Name</label><input type="text" name="CBTIT3" id="CBTIT3" maxlength="30" value="">
</div>
</td>
<td align="right" valign="top" width="50%">
<div class="mercury-plaintextheading">
<div style="margin-top:7px">
<label>Date Signed</label> 12/29/21
</div>
</div>
</td>
</tr>
</tbody>
</table>
</span>
<!-- table body end -->
</td>
</tr>
<tr>
<td class="box-bottom"></td>
</tr>
</tbody>
</table>
<div id="idThemeBorder-buttons" class="buttons">
<input type="image" name="submitimage" id="submitimage" src="/images/en_us/button_submit.gif">
</div>
</form>Text Content
APPLICATION FOR NEW CREDIT ACCOUNT
paper/fax version available
Please address the fields marked in red to continue
Have you worked with a URI employee? If so, please provide their name.
Representative Name
Sales Rep #
Business Address
* Business Name
* Occupancy Status OwnRent
* Address
Address 2
* City
* State/Province Alabama Alaska Arizona Arkansas California Colorado Connecticut
Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa
Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota
Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico
New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto
Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont
Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Alberta
British Columbia Manitoba New Brunswick New Labrador Northwest Territories Nova
Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon
Aguascalientes Baja California Norte Baja California Sur Chihuahua Colima
Campeche Coahuila Chiapas Distrito Federal Durango Guerrero Guanajuato Hidalgo
Jalisco Michoacan Morelos Nayarit Nuevo Leon Oaxaca Puebla Quintana Roo
Queretaro Sinaloa San Luis Potosi Sonora Tabasco Tlaxcala Tamaulipas Veracruz
Yucatan Zacatecas
* Zip/Postal Code
* Telephone Number
Fax Number
Account Payable Contact Information
* A/P Contact Name
* Email Address
Billing Address same as Business Address
* Billing Address
* City
* State/Province Alabama Alaska Arizona Arkansas California Colorado Connecticut
Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa
Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota
Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico
New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto
Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont
Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Alberta
British Columbia Manitoba New Brunswick New Labrador Northwest Territories Nova
Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon
Aguascalientes Baja California Norte Baja California Sur Chihuahua Colima
Campeche Coahuila Chiapas Distrito Federal Durango Guerrero Guanajuato Hidalgo
Jalisco Michoacan Morelos Nayarit Nuevo Leon Oaxaca Puebla Quintana Roo
Queretaro Sinaloa San Luis Potosi Sonora Tabasco Tlaxcala Tamaulipas Veracruz
Yucatan Zacatecas
* Zip/Postal Code
Business Information
* Date Established M/D/YYYY
* Anticipated Monthly Charge Amt.
* Nature of Business
* Contractor License Number
* Type of Business Corporation
Partnership
Sole Proprietor
* Tax Exempt Status? No Yes, (Certificate Required)
Tax ID #
or Resale #
Owners (If Applicant is Sole Owner or Partnership) or Officers (If Corporation)
* Owner/Officer #1 Name
* Title
SSN / SIN
* Address
* City
* State/Province Alabama Alaska Arizona Arkansas California Colorado Connecticut
Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa
Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota
Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico
New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto
Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont
Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Alberta
British Columbia Manitoba New Brunswick New Labrador Northwest Territories Nova
Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon
Aguascalientes Baja California Norte Baja California Sur Chihuahua Colima
Campeche Coahuila Chiapas Distrito Federal Durango Guerrero Guanajuato Hidalgo
Jalisco Michoacan Morelos Nayarit Nuevo Leon Oaxaca Puebla Quintana Roo
Queretaro Sinaloa San Luis Potosi Sonora Tabasco Tlaxcala Tamaulipas Veracruz
Yucatan Zacatecas
* Zip/Postal Code
* Telephone Number
Owner/Officer #2 Name
Title
SSN / SIN
Address
City
State/Province Alabama Alaska Arizona Arkansas California Colorado Connecticut
Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa
Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota
Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico
New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto
Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont
Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Alberta
British Columbia Manitoba New Brunswick New Labrador Northwest Territories Nova
Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon
Aguascalientes Baja California Norte Baja California Sur Chihuahua Colima
Campeche Coahuila Chiapas Distrito Federal Durango Guerrero Guanajuato Hidalgo
Jalisco Michoacan Morelos Nayarit Nuevo Leon Oaxaca Puebla Quintana Roo
Queretaro Sinaloa San Luis Potosi Sonora Tabasco Tlaxcala Tamaulipas Veracruz
Yucatan Zacatecas
Zip/Postal Code
Telephone Number
Please supply the following information to help us serve your accounts
* 1. Do you require a purchase order number on each invoice?
If Yes, equipment will not be released unless provided. YesNo
* 2. Do you require a monthly statement? YesNo
* 3. We elect to 'Go Green' by receiving invoices and statements via email.
YesNo
* 4. Rental Protection Plan (RPP) will be charged on every contract. To opt out
of this charge,
please send a Certificate of Insurance to rppoptout@ur.com
* 5. Have you ever had a previous account with United Rentals or its
subsidiaries? YesNo
If Yes, Account Number
* 6. Will you provide a certificate of insurance evidencing general liability
coverage
and property coverage naming United Rentals as loss payee and additional
insured? YesNo
Open Account Credit Terms
1. Each invoice is due upon receipt.
2. If equipment is rented for more than 4 weeks, periodic unsigned invoices
will be issued for rental charge due. All such invoices are due upon
receipt.
3. At the discretion of United Rentals, any account with a delinquent balance
may be placed on a cash basis any time, and the equipment picked up without
notice.
4. United Rentals files preliminary lien notices and mechanics liens whenever
necessary or required by law. This is a company policy, and is not a
reflection of your credit standing.
5. For each delinquent account, customer agrees to pay a monthly service charge
equal to 2% of the past due balance or the maximum service charge permitted
by law in the state where the contract is signed.
6. Customer agrees to pay all reasonable attorney fees, collection costs, and
court costs incurred by United Rentals in enforcing these terms and
conditions.
7. Customer authorizes United Rentals to obtain credit reports, trade reports,
and bank references for the purpose of determining the extension or
continuation of credit to customer.
8. Customer agrees to the terms and conditions as stated on each and every
United Rental's invoice.
The undersigned warrants that all information is correct, has read, accepted and
agrees to be bound by all of the terms set forth in this document and in each
rental contract entered into by the undersigned or his agents. It is understood
and agreed that the undersigned specifically consents to United Rentals
investigating of the applicant's credit history and may utilize credit reporting
services for information on the undersigned. Facsimile copies will be accepted
as originals.
The Federal Equal Credit Opportunity Act/regulation B prohibits creditors from
discriminating against credit applicants on the basis of race, color, religion,
national origin, sex, marital status, age (provided the applicant has the
capacity to enter into a binding contract); because all or part of the
applicant's income derives from any public assistance program; or because the
applicant has, in good faith, exercised any right under the Consumer Credit
Protection Act. The federal agency that administers compliance with the law
concerning this credit is the Federal Trade Commission, Division of Credit
Practices, 6TH and Pennsylvania Avenue, NW Washington, D.C. 20580.
In the event Credit Applicant enters into an agreement with United Rentals to
purchase used rental or transportation equipment, Credit Applicant is hereby
notified that United Rentals has assigned its rights (but not its obligations)
in such agreement to United Rentals Exchange, LLC., a qualified intermediary, as
part of a Section 1031 like-kind exchange program.
By checking this box, I authorize my signature and hereby agree to the Credit
Terms and conditions listed on this application for a new credit account; in
addition, I hereby authorize the bank named above to release information
requested for the purpose of obtaining and/or reviewing credit.
* Print Name
Date Signed 12/29/21
Consent to obtain consumer credit report
The undersigned individual who is either a principal of the credit applicant or
a sole proprietorship of the credit applicant, recognizing that his or her
individual credit history may be a factor in the evaluation of the credit
history of the applicant, hereby consents to and authorizes the use of a
consumer credit report on the undersigned by the above named business credit
grantor, from time to time as may be needed, in the credit evaluation process.
Continuing personal guarantee
The undersigned hereby unconditionally guarantee(s) the full and prompt payment
to United Rentals when due all indebtedness, obligations, and liabilities of the
customer named in the Credit Application, including all amounts now owing and
arising in the future, and including any interest, attorney fees, and collection
and court costs. The undersigned agrees to be personally bound by all credit
terms of this Credit Application. This guarantee shall continue in force until
notice in writing sent by certified mail, return receipt requested, is received
by United Rentals. This notice shall specify the date of termination, not to be
less than seven (7) days after the notice and shall not affect any charges for
transactions with the customer that were entered into prior to the termination
date.
The undersigned personal guarantor, recognizing that his or her individual
credit history may be a necessary factor in the evaluation of this personal
guarantee, hereby consents to and authorizes the use of a consumer credit report
on the undersigned, by the above named business credit grantor, from time to
time as may be needed, in the credit evaluation process.
By checking this box, I authorize my signature and hereby agree to all the terms
and conditions listed on this application for a new credit account, in addition
to those listed in the "Continuing personal guarantee" section of this form.
Print Name
Date Signed 12/29/21