CLIENT/DEALER APPLICATION DISCLOSURE AGREEMENT
I/We understand that information is given for the purpose of obtaining credit. I/We warrant that all of the information is true. I/We hereby authorize all of the persons or companies on the application to release to Interstate Billing Service, Inc., or its representatives, any information with regard to my/our financial condition, as may reasonably have a bearing on this application. I/We authorize Interstate Billing Service, Inc. to obtain a consumer credit report on my/our personal credit history if necessary, in accordance with the Federal Fair Credit Reporting Act, and to use this report in making decisions concerning my/our credit worthiness. As required by Section 4017 (d) (2) of the Small Business Jobs Act on 2010, I/we hereby certify to Interstate Billing Service, Inc. and its affiliates that principles of Merchant and its affiliates have not been convicted of, or pleaded nolo contendere to, a sex offense against a minor (as such terms are defined in section 111 of the Sex Offender Registration and Notification Act (42 U.S.C. 16911)).

I/We agree to conduct transactions with Interstate Billing Service, Inc., its successors, assigns, and/or designees, by electronic means, including as appropriate through use and receipt of electronic records and electronic signatures.