DE RIGO REM BUSINESS CREDIT APPLICATION

Do you have an existing account with De Rigo Rem If yes please provide here

For Buying Group Members only: Buying Group Name:

Buying Group Name

Number

BUSINESS LEGAL INFORMATION (required)

Company Name*

DBA

Address*

UnitSuite

City*

State/Province*

Zip/ Postal*

Country*

Phone*

Format: (000) 000-0000.

Fax

Format: (000) 000-0000.

Email*

example@example.com

AP Contact*

AP Email*

example@example.com

Yes

If Yes, Name of Group

Group Number

Limited Liability CompanyPartnershipCorporationSole Proprietorship

Yes (please attach copy)Yes, I have submitted it through the cert express link: https://app.certexpress.com/?c=3342367646694b3367345032416245633848493dNo (if No, taxes may apply)

The undersigned individual, who is an authorized representative of the applicant, hereby consents to and authorizes Rem Optical Company Inc. to apply the appropriate sales tax to purchases made by above applicant, unless the State approved exemption certificate is provided. Rem Optical Company, Inc. is hereby authorized to verify exemption eligibility

Authorized Signature*

Title*

Print Name*

Date*

Date

Company name*

Contact persons name*

Phone*

Format: (000) 000-0000.

Email*

example@example.com

Company name*

Contact persons name*

Phone*

Format: (000) 000-0000.

Email*

example@example.com

Bank Name*

Account*

Contact Name

Phone*

I, the undersigned, do hereby acknowledge that the above information is complete and accurate and is being provided to obtain a line of credit with Rem Optical Company Inc. dba De Rigo Rem, referred to herein as "the company". The undersigned individual, who is an authorized representative of the applicant, hereby consents to and authorizes verification of credit for the above applicant and grantsaccesstopersonalandbusiness credit history nowandthroughout thefinancing term.Should credit availability be granted, all decisions with respect to the extension or continuation shall be the sole discretion of the company, which may increase, decrease, or terminate the credit availability at any time. The company may report information about the account status to credit bureaus. Timely payments as well as late or missed payments are among the information which may be reflected in your credit report. The above applicant agrees that all due balances will be paid according to the agreed upon payment terms. Balances not paid by the due date will bear interest at the rate of 1.5% monthly (18% per annum) until paid in full. Balances due shall be paid in full prior to changes in ownership. Applicant will bear court costs, attorney fees and any other costs incurred by for cases placed for collections. I have read, understood, and I agree to the Terms of Use and Privacy Policy of the company. I understand that additional details can be viewed online by visiting www.derigo.us/termsofuse.aspx and www.derigo.us/privacypolicy.aspx

Authorized Signature*

Title*

Print Name*

Date*

Date

The undersigned, as an official representative of the applicant (i.e. owner, director, officer, partner or shareholder), further agrees to be personally liable for any balances that may hereafter become due to Rem Optical Company Inc.and/or its affiliates and to have access to my personal and business credit history now and throughtout the financing term. The guarantee shall be continuing and shall survive the ownership transfer or the sale of the applicant. The undersigned agrees to remain personally responsible and liable for any indebtedness of the applicant until the indebtedness is paid in full.

Authorized Signature

Title

Print Name

Date

BUSINESS CREDIT APPLICATION

BUSINESS/TRADE REFERENCES

BANK REFERENCE