New Account Application Form

Today's Date: *

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How did you hear about us? * Referral Web Search Other

Account Name: *

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Primary Account Holder: *

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Title:

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Cell Phone:

Primary Phone: *

Address: *

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Address Line 2

City *

Region/State/Province *

Postal / Zip code *

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Email *

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Accounting Contact: *

Phone: *

Email *

Tax Exempt: * YES NO

ACCOUNT APPROVAL MAY REQUIRE UP TO 72 BUSINESS HOURS, CONTINGENT ON THE SUCCESSFUL VERIFICATION OF REFERENCES, INSURANCE, AND CREDIT.

CREDIT CARD AUTHORIZATION

(at this time we do not accept debit cards)

Cardholder Name: *

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Card Number *

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Expiration Date: *

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CVV: *

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Card * VISA MC AMEX DISCOVER

Billing Address: *

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City *

Region/State/Province *

Postal / Zip code *

Country *

Identification/DL No.: *

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ID/DL Expiration: *

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Please add signature

PLEASE INCLUDE LEGIBLE FRONT and BACK COPIES OF CREDIT CARD AND CARDHOLDER'S IDENTIFICATION/DL.

INSURANCE TERMS

A valid Certificate of Insurance must be issued naming Scheimpflug Photo Equipment, LLC as Additional Loss Payee for rented / miscellaneous equipment, all risk, worldwide. Coverage must match or be above the rental order replacement value amount. Scheimpflug must also be listed as Additional Insurded for $1,000,000 USD with respect to General Liability.

An example COI for new accounts is available online at www.scheimpflug.com/insuranceinfo

In The Absence Of A Valid Certificate Of Insurance, A Hold For The Full Replacement Value Of The Rental Package Will Be Placed On The Account Credit Card Upon Pickup And/or Delivery Of The Order. Scheimpflug Has No Control On When Holds Placed On Charge Cards Are Released By Your Banking Institution.

COI: * YES NO

Broker:

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Phone:

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Insurance Company:

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Policy No.:

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