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URL:
https://apply.ur.com/apply/index/index/r/11538/n/George%20Rudd
Submission: On March 14 via manual from US — Scanned from DE
Submission: On March 14 via manual 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"><input type="hidden" name="csrf" value="82ec9191e85ad7ee5d7199c4c65fd88c-a5623348d0238e758f31815ff3566976">
<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="George Rudd">
</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="11538">
</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="" maxlength="30" value="">
</div>
<div class="fixedWidthElement">
<label for="CBREFB">DBA if Applicable</label><input type="text" name="CBREFB" id="CBREFB" 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="" value="O">Own</label><label><input type="radio" name="CBOWNR" 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="" 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="" maxlength="20" value="">
</div>
<div class="fixedWidthElement">
<label for="CBASTE">* State/Province</label><select name="CBASTE" id="CBASTE" 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="" maxlength="10" value="">
</div>
<div class="fixedWidthElement">
<label for="CBAACDAPHN">* Business Phone</label><input type="text" name="CBAACDAPHN" id="CBAACDAPHN" required="" value="">
</div>
<div class="fixedWidthElement">
<label for="CBACD3PHN3">* Cell Phone</label><input type="text" name="CBACD3PHN3" id="CBACD3PHN3" 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="" maxlength="30" value="">
</div>
<div class="fixedWidthElement">
<label for="CBAPEM">* Email Address</label><input type="text" name="CBAPEM" id="CBAPEM" required="" maxlength="50" value="">
</div>
<div style="text-align:right;padding-right:25px;"> (for invoicing & statements) </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="" maxlength="30" value="">
</div>
<div class="fixedWidthElement">
<label for="CBBCTY">* City</label><input type="text" name="CBBCTY" id="CBBCTY" required="" maxlength="20" value="">
</div>
<div class="fixedWidthElement">
<label for="CBBSTE">* State/Province</label><select name="CBBSTE" id="CBBSTE" 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="" maxlength="10" value="">
</div>
<div class="fixedWidthElement"> </div>
<div class="fixedWidthElement">
<label for="CBFIDpound">Federal Tax ID #</label><input type="text" name="CBFIDpound" id="CBFIDpound" 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="" 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="" maxlength="9" value="">
</div>
<div class="fixedWidthElement">
<label for="CBBSOF">* Nature of Business</label><input type="text" name="CBBSOF" id="CBBSOF" required="" maxlength="20" value="">
</div>
<div class="fixedWidthElement">
<label for="CBSTA3">State where registered or incorporated</label><select name="CBSTA3" id="CBSTA3">
<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="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="" value="C">Corporation</label><br><label><input type="radio" name="CBTYPE" required="" value="P">Partnership</label><br><label><input type="radio"
name="CBTYPE" required="" value="S">Sole Proprietor</label><br><label><input type="radio" name="CBTYPE" required="" value="L">LLC</label><br><label><input type="radio" name="CBTYPE" required=""
value="G">Government</label><br><label><input type="radio" name="CBTYPE" required="" value="O">Other</label>
</td>
</tr>
</tbody>
</table>
<div class="fixedWidthElement">
<label for="CBTAX">* Tax Exempt Status?</label><select name="CBTAX" id="CBTAX" 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="CBRSAL">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="" maxlength="30" value="">
</div>
<div class="fixedWidthElement">
<label for="CBTIT1">* Title</label><input type="text" name="CBTIT1" id="CBTIT1" 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="" maxlength="30" value="">
</div>
<div class="fixedWidthElement">
<label for="CBCTY1">* City</label><input type="text" name="CBCTY1" id="CBCTY1" required="" maxlength="15" value="">
</div>
<div class="fixedWidthElement">
<label for="CBSTA1">* State/Province</label><select name="CBSTA1" id="CBSTA1" 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="" maxlength="10" value="">
</div>
<div class="fixedWidthElement">
<label for="CBACD1PHN1">* Telephone Number</label><input type="text" name="CBACD1PHN1" id="CBACD1PHN1" 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 service 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="" value="Y">Yes</label><label><input type="radio" name="CBPONI" 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="" value="Y">Yes</label><label><input type="radio" name="CBSREQ" 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="" value="Y">Yes</label><label><input type="radio" name="CBEMYN" 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="CBUDF3-label">
<label for="CBUDF3">* 5. 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="" value="Y">Yes</label><label><input type="radio" name="CBUDF3" required="" value="N">No</label>
</td>
</tr>
</tbody>
</table>
<table class="radiotable">
<tbody>
<tr>
<td id="CBPREV-label">
<label for="CBPREV">* 6. 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="" value="Y">Yes</label><label><input type="radio" name="CBPREV" 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="CBUDF6-label">
<label for="CBUDF6">* 7. Has applicant or any of its owners, officers, directors, or managing members, or any guarantor, ever been a debtor in a voluntary or involuntary bankruptcy filing, had a receiver appointed, or made
an assignment for benefit of creditors?</label>
</td>
<td class="fixedwidth">
<label><input type="radio" name="CBUDF6" id="CBUDF6" required="" value="Y">Yes</label><label><input type="radio" name="CBUDF6" required="" value="N">No</label>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
</tbody>
</table>
<div class="mercury-heading">Credit Application and Agreement Terms & Conditions</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 applicant identified above ("Applicant") hereby enters into this Credit Application and Agreement ("Credit Agreement") with United Rentals (North America), Inc. ("UR"). Applicant hereby applies to UR for credit,
specifically consents to UR investigating Applicant's credit history and obtaining credit reports, and authorizes the release of Applicant's bank account information. If credit is extended, Applicant acknowledges that UR
requires payment upon receipt of the invoice. Invoices are considered past due after the date of such invoice. If Applicant fails to timely pay an invoice, Applicant agrees to pay a service charge to UR on such delinquent
invoice(s) until fully paid, at the maximum rate allowed by the laws and jurisdiction of the originating location stated on the invoice, and also agrees to pay UR collection costs and/or attorney's fees in an amount that is
not less than 25% of the outstanding balance owed. At the discretion of UR, any account with a delinquent balance may be placed on a cash basis at any time, and UR may pick up the equipment without notice to Applicant.
Additionally, UR reserves the right to pursue remedies available to it at law or in equity. By signing below, Applicant agrees to be bound by the Online Rental Agreement Terms and Conditions
<a href="https://www.unitedrentals.com/legal/">https://www.unitedrentals.com/legal/</a>, as amended from time to time (collectively the "Rental Agreement"). A copy of the Rental Agreement is available upon request. Such terms
and conditions include, but are not limited to, indemnification and limitation of liability provisions that may affect Applicant's liability. Applicant acknowledges that the Rental Agreement terms and conditions may change
over time and agrees to be bound by such terms and conditions in use at the time of each rental or sales transaction in the jurisdiction where the purchase or rental occurs. Effective February 2, 2024 where permitted by law,
United Rentals may impose a surcharge of 2.0% for credit card payments on charge accounts. This surcharge is not greater than our merchant discount rate for credit card transactions and is subject to sales tax in some
jurisdictions. </p>
<p> The parties hereby agree that for so long as this Credit Agreement is in place, Applicant is not required to sign the Rental Agreement provided that Applicant signs a form provided by UR for the sole purpose of acknowledging
receipt of the equipment, safety notices and operations manuals. The parties further agree that any purchase order, scope of work, work order, agreement, or similar document issued by Applicant shall be signed by UR for
Applicant's record keeping purposes only. Any terms contained therein, other than amount and types of equipment ordered, time and place for delivery, price, and estimated Rental Period, shall be superseded and replaced by the
terms and conditions of the Rental Agreement. </p>
<p style="font-weight:bold;"> UR reserves the right to file preliminary lien notices and/or mechanics liens for work done in states where these notices are required by state law in order to protect our lien rights. </p>
<div style="font-size:16px;font-weight:bold;">CREDIT APPLICATION AND AGREEMENT</div>
<p> The Federal Equal Credit Opportunity Act 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 creditor is the Federal Trade Commission, Division of Credit Practices, 6TH and Pennsylvania Avenue, NW Washington, D.C. 20580. </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="" 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 Terms and Conditions listed on this application for a new credit account.</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">* Authorized Signature</label><input type="text" name="CBONM3" id="CBONM3" 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> 03/14/24
</div>
</div>
</td>
</tr>
</tbody>
</table>
<div class="mercury-heading">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> In consideration of the extension of credit to above listed applicant, the undersigned, jointly, severally and unconditionally guarantees and promises to pay all amounts now owing or which may hereinafter become owing by the
Applicant to United Rentals ("UR"). It is understood and agreed that this is a continuing guaranty and UR shall not be obligated to notify the undersigned of the dates or amounts of any such credit, that the undersigned waives
demand and notice of default and agrees that any extension of time or other forbearance, which may be granted by UR shall not affect or alter UR's rights under this guaranty. </p>
<p> The undersigned further waives: (a) notice of acceptance of this guaranty; (b) any demand for payment under this guaranty; (c ) benefit of all exemptions and homestead laws; (d) all set-offs and counterclaims; and (e) all
other notices to which the undersigned might otherwise be entitled. The undersigned for themselves and the Applicant further agrees to pay a service charge to UR at the maximum rate allowed by the laws of the jurisdiction
where the originating UR location(s) stated on the invoice(s) is located on all delinquent balance(s) as well as all costs and expenses UR incurs in connection with the collection of any delinquent balance or any other default
by the Applicant on any agreement or transaction the Applicant may enter into with UR, including without limitation reasonable attorney's fees and all other fees arising from collection. This is a guaranty of payment and not
of collection and the undersigned further waives any right to require that any action be brought against the Applicant or other person or to require that resort be had to any security. The undersigned's obligation shall remain
effective and be enforceable regardless of any subsequent incorporation, reorganization, merger or consolidation transfer or sale of the Applicant or any other change in the composition, nature, personnel, or location of the
Applicant. This guaranty shall inure to the benefit of UR, its successors and assigns and shall bind the heirs, executors, personal representatives, administrators, assignees, purchasers, and other successors of the
undersigned. If any provision or part of this guaranty is in conflict with any applicable statute or rule of law, such provision, or part thereof, as the case may be, shall be deemed null and void to the extent that it may
conflict therewith, but without invalidating the remaining provisions hereof or the remaining part of such provision. </p>
<p> The undersigned's obligations hereunder may be canceled only by written notice delivered to UR by certified mail, with proof of delivery. Upon receipt by UR of such cancellation notice, the undersigned shall not be liable
for any further extensions of credit to the Applicant; however, the undersigned shall continue to be liable for all indebtedness of Applicant incurred prior to the date of UR's receipt of the cancellation notice, together with
all pre- and post- cancellation service charges, reasonable costs of collection, including attorney's fees, incurred in UR's efforts to collect any indebtedness incurred prior to the date of receipt of the cancellation notice.
The undersigned agrees that any and all claims of the undersigned against the Applicant shall be subordinate and subject in right of payment to the prior payment in full of all indebtedness to UR by Applicant. </p>
<p> In consideration of UR's extension of credit to Applicant, the undersigned hereby expressly waives any right of trial by jury in any proceeding arising out of, or relating to, this guaranty, to the extent allowed by the laws
of the State of Delaware. The undersigned further consents to jurisdiction and venue for any such action in Kent County, State of Delaware. The undersigned recognizes the obligation both of the Applicant and the undersigned to
cause that portion of all payments received by Applicant which include payment to Applicant for the equipment and supplies furnished by UR pursuant to this agreement to be held in a separate account in trust for payment to UR.
The undersigned agrees that the Applicant shall not use said payments for any other purpose until payment in full has been made to UR. The undersigned agrees to act as a fiduciary for payment to UR in exchange for the
Applicant's ability to rent and/or purchase eq uipment and supplies on credit. The undersigned agrees that any failure to hold payments in trust for UR shall create a debt which is not dischargeable in bankruptcy and which
shall be an exception to discharge pursuant to the terms of 11 U.S.C. §523(a)(4) and (6). The undersigned agrees to be bound, by the Online Rental Agreement Terms and Conditions
[<a href="https://www.unitedrentals.com/legal/rental-service-terms-us">https://www.unitedrentals.com/legal/rental-service-terms-us</a>], as amended from time to time (collectively the "Rental Agreement"). Such terms and
conditions include, but are not limited to, indemnification and limitation of liability provisions that may affect the undersigned's liability. The undersigned acknowledges that the Rental Agreement terms and conditions may
change over time and agrees to be bound by such terms and conditions in use at the time of each rental or sales transaction in the jurisdiction where the purchase or rental occurs. </p>
<p> The terms and conditions of the Rental Agreement are incorporated herein by reference and constitute a part of this Credit Agreement and guaranty, regardless of whether the Rental Agreement is executed by an authorized
representative of Applicant or the undersigned. A copy of the current terms and conditions of the Rental Agreement is available upon request. </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">Authorized Signature</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> 03/14/24
</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
DBA if Applicable
* 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
* Business Phone
* Cell Phone
Fax Number
Account Payable Contact Information
* A/P Contact Name
* Email Address
(for invoicing & statements)
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
Federal Tax ID #
Business Information
* Date Established M/D/YYYY
* Anticipated Monthly Charge Amt.
* Nature of Business
State where registered or incorporated 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
Contractor License Number
* Type of Business Corporation
Partnership
Sole Proprietor
LLC
Government
Other
* Tax Exempt Status? No Yes, (Certificate Required)
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 service 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. Will you provide a certificate of insurance evidencing general liability
coverage
and property coverage naming United Rentals as loss payee and additional
insured? YesNo
* 6. Have you ever had a previous account with United Rentals or its
subsidiaries? YesNo
If Yes, Account Number
* 7. Has applicant or any of its owners, officers, directors, or managing
members, or any guarantor, ever been a debtor in a voluntary or involuntary
bankruptcy filing, had a receiver appointed, or made an assignment for benefit
of creditors? YesNo
Credit Application and Agreement Terms & Conditions
The applicant identified above ("Applicant") hereby enters into this Credit
Application and Agreement ("Credit Agreement") with United Rentals (North
America), Inc. ("UR"). Applicant hereby applies to UR for credit, specifically
consents to UR investigating Applicant's credit history and obtaining credit
reports, and authorizes the release of Applicant's bank account information. If
credit is extended, Applicant acknowledges that UR requires payment upon receipt
of the invoice. Invoices are considered past due after the date of such invoice.
If Applicant fails to timely pay an invoice, Applicant agrees to pay a service
charge to UR on such delinquent invoice(s) until fully paid, at the maximum rate
allowed by the laws and jurisdiction of the originating location stated on the
invoice, and also agrees to pay UR collection costs and/or attorney's fees in an
amount that is not less than 25% of the outstanding balance owed. At the
discretion of UR, any account with a delinquent balance may be placed on a cash
basis at any time, and UR may pick up the equipment without notice to Applicant.
Additionally, UR reserves the right to pursue remedies available to it at law or
in equity. By signing below, Applicant agrees to be bound by the Online Rental
Agreement Terms and Conditions https://www.unitedrentals.com/legal/, as amended
from time to time (collectively the "Rental Agreement"). A copy of the Rental
Agreement is available upon request. Such terms and conditions include, but are
not limited to, indemnification and limitation of liability provisions that may
affect Applicant's liability. Applicant acknowledges that the Rental Agreement
terms and conditions may change over time and agrees to be bound by such terms
and conditions in use at the time of each rental or sales transaction in the
jurisdiction where the purchase or rental occurs. Effective February 2, 2024
where permitted by law, United Rentals may impose a surcharge of 2.0% for credit
card payments on charge accounts. This surcharge is not greater than our
merchant discount rate for credit card transactions and is subject to sales tax
in some jurisdictions.
The parties hereby agree that for so long as this Credit Agreement is in place,
Applicant is not required to sign the Rental Agreement provided that Applicant
signs a form provided by UR for the sole purpose of acknowledging receipt of the
equipment, safety notices and operations manuals. The parties further agree that
any purchase order, scope of work, work order, agreement, or similar document
issued by Applicant shall be signed by UR for Applicant's record keeping
purposes only. Any terms contained therein, other than amount and types of
equipment ordered, time and place for delivery, price, and estimated Rental
Period, shall be superseded and replaced by the terms and conditions of the
Rental Agreement.
UR reserves the right to file preliminary lien notices and/or mechanics liens
for work done in states where these notices are required by state law in order
to protect our lien rights.
CREDIT APPLICATION AND AGREEMENT
The Federal Equal Credit Opportunity Act 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 creditor
is the Federal Trade Commission, Division of Credit Practices, 6TH and
Pennsylvania Avenue, NW Washington, D.C. 20580.
By checking this box, I authorize my signature and hereby agree to the Terms and
Conditions listed on this application for a new credit account.
* Authorized Signature
Date Signed 03/14/24
Personal Guarantee
In consideration of the extension of credit to above listed applicant, the
undersigned, jointly, severally and unconditionally guarantees and promises to
pay all amounts now owing or which may hereinafter become owing by the Applicant
to United Rentals ("UR"). It is understood and agreed that this is a continuing
guaranty and UR shall not be obligated to notify the undersigned of the dates or
amounts of any such credit, that the undersigned waives demand and notice of
default and agrees that any extension of time or other forbearance, which may be
granted by UR shall not affect or alter UR's rights under this guaranty.
The undersigned further waives: (a) notice of acceptance of this guaranty; (b)
any demand for payment under this guaranty; (c ) benefit of all exemptions and
homestead laws; (d) all set-offs and counterclaims; and (e) all other notices to
which the undersigned might otherwise be entitled. The undersigned for
themselves and the Applicant further agrees to pay a service charge to UR at the
maximum rate allowed by the laws of the jurisdiction where the originating UR
location(s) stated on the invoice(s) is located on all delinquent balance(s) as
well as all costs and expenses UR incurs in connection with the collection of
any delinquent balance or any other default by the Applicant on any agreement or
transaction the Applicant may enter into with UR, including without limitation
reasonable attorney's fees and all other fees arising from collection. This is a
guaranty of payment and not of collection and the undersigned further waives any
right to require that any action be brought against the Applicant or other
person or to require that resort be had to any security. The undersigned's
obligation shall remain effective and be enforceable regardless of any
subsequent incorporation, reorganization, merger or consolidation transfer or
sale of the Applicant or any other change in the composition, nature, personnel,
or location of the Applicant. This guaranty shall inure to the benefit of UR,
its successors and assigns and shall bind the heirs, executors, personal
representatives, administrators, assignees, purchasers, and other successors of
the undersigned. If any provision or part of this guaranty is in conflict with
any applicable statute or rule of law, such provision, or part thereof, as the
case may be, shall be deemed null and void to the extent that it may conflict
therewith, but without invalidating the remaining provisions hereof or the
remaining part of such provision.
The undersigned's obligations hereunder may be canceled only by written notice
delivered to UR by certified mail, with proof of delivery. Upon receipt by UR of
such cancellation notice, the undersigned shall not be liable for any further
extensions of credit to the Applicant; however, the undersigned shall continue
to be liable for all indebtedness of Applicant incurred prior to the date of
UR's receipt of the cancellation notice, together with all pre- and post-
cancellation service charges, reasonable costs of collection, including
attorney's fees, incurred in UR's efforts to collect any indebtedness incurred
prior to the date of receipt of the cancellation notice. The undersigned agrees
that any and all claims of the undersigned against the Applicant shall be
subordinate and subject in right of payment to the prior payment in full of all
indebtedness to UR by Applicant.
In consideration of UR's extension of credit to Applicant, the undersigned
hereby expressly waives any right of trial by jury in any proceeding arising out
of, or relating to, this guaranty, to the extent allowed by the laws of the
State of Delaware. The undersigned further consents to jurisdiction and venue
for any such action in Kent County, State of Delaware. The undersigned
recognizes the obligation both of the Applicant and the undersigned to cause
that portion of all payments received by Applicant which include payment to
Applicant for the equipment and supplies furnished by UR pursuant to this
agreement to be held in a separate account in trust for payment to UR. The
undersigned agrees that the Applicant shall not use said payments for any other
purpose until payment in full has been made to UR. The undersigned agrees to act
as a fiduciary for payment to UR in exchange for the Applicant's ability to rent
and/or purchase eq uipment and supplies on credit. The undersigned agrees that
any failure to hold payments in trust for UR shall create a debt which is not
dischargeable in bankruptcy and which shall be an exception to discharge
pursuant to the terms of 11 U.S.C. §523(a)(4) and (6). The undersigned agrees to
be bound, by the Online Rental Agreement Terms and Conditions
[https://www.unitedrentals.com/legal/rental-service-terms-us], as amended from
time to time (collectively the "Rental Agreement"). Such terms and conditions
include, but are not limited to, indemnification and limitation of liability
provisions that may affect the undersigned's liability. The undersigned
acknowledges that the Rental Agreement terms and conditions may change over time
and agrees to be bound by such terms and conditions in use at the time of each
rental or sales transaction in the jurisdiction where the purchase or rental
occurs.
The terms and conditions of the Rental Agreement are incorporated herein by
reference and constitute a part of this Credit Agreement and guaranty,
regardless of whether the Rental Agreement is executed by an authorized
representative of Applicant or the undersigned. A copy of the current terms and
conditions of the Rental Agreement is available upon request.
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.
Authorized Signature
Date Signed 03/14/24