3405 NW 113 Court, Miami, FL 33178 Phone: 305 513-0484 Fax: 305 728-8715

Cloudesuite New Customer Set Up Form

Branch No: _____
Company Name: SINERGIA E INNOVACION EN TECNOLOGIA E INFRAESTRUCTURA, C.A.

Address: STREET 59 BETWEEN AV 15 AND 16 CC VILLA HARVARD LEVEL 1 LOCAL PA-08 SECTOR ZIRUMA

City, State, Zip: MARACAIBO, ESTADO ZULIA

Country: VENEZUELA

Contact Name: NELSON GUTIERREZ

Office Number: +584246155620 Cell Number: +584246155620

Contact’s E-mail: NGUTIERREZ@TERGYCA.COM

Taxable ___ Yes or ___ NO Taxing County: _______________________________

Sales Rep Out: _________ ________________ Website: WWW.TERGYCA.COM

Ship to Address: ______________________________________________________________________

For Term Accounts:

AP Contact Name: ____________________________________________________________________

AP Contact Phone: _____________________________________________________________________

AP e-mail address for invoices / statements: ________________________________________________

For Credit Department’s Use: Customer Number Assigned: __ __ __ __ __ __ __

Terms: ___________________ DUNS: _____________________________________________

Paydex: _________ Credit Limit: _________________________________________

Group #: (if applicable) _________________________________________________________________