Ivanti US Account Set up Form

DIVISION: _______HEAT ______LANDESK/APPSENSE/SHAVLIK ________WAVELINK/NAURTECH

PARENT COMPANY:
(If Applicable)

COMPANY NAME:

COMPANY ADDRESS:

BILLING ADDRESS:
(If Different from above)

TYPE OF BUSINESSS: NO OF EMPLOYEES:

TELEPHONE NO: FAX NO:

A/P CONTACT NAME: A/P TELEPHONE #:

A/P E-MAIL ADDRESS:

(All invoices are E-mailed automatically from our accounting system)

CREDIT AMOUNT REQUESTED:

(Currency to be invoiced in USD)
**Credit Limits of $50k or more, must include Financial Statements
(Balance Sheet, Income Statement, and Statement of Cash Flows)

Please note: All purchases are subject to our Standard Terms & Conditions, which are included on our
invoices. By signing below you are agreeing to be bound by those Terms & Conditions, a copy of, which
are available on request.

NAME OF APPLICANT: TITLE:

SIGNATURE: DATE:

Please return completed form to sender or ar@ivanti.com

Include reseller agreement or tax exempt cerificate if applicable.