The application below is not considered a binding agreement. The information provided will be used to prepare a license agreement, and will not be distributed to any third party organizations. If you have any questions about the information requested below, please feel free to contact us directly.
Customer Information:
Merchant/Company Name:  * Postal Code:
Contact Name:  * Country:
Position: Phone:  *
Billing Address: Fax:
City: Email Address:  *
State: Web Site Address:
Market Research:
Referred by / How did you hear about the ORC?

ORC Package:
 Lite
 Standard
 Advanced
 Enterprise
Module Type:
Training Course Seminar Conference
Distance Learning Membership Soft Goods
Other:
Transaction & Tax Information:
Average Transaction Amount:
           Average Number Of Transactions / Month:
Federal Tax ID or DUNNS Number:
References:
(1) Credit/Trade Reference: (2) Credit/Trade Reference:
Account Number: Account Number:
Contact Name: Contact Name:
Phone Number: Phone Number:
Merchant authorizes the ORC to investigate and confirm the information contained herein and hereby certifies that all the information provided, including Merchant's legal status, is true, correct, and complete. Merchant hereby authorizes the ORC to utilize credit bureau/reporting agencies and /or its own agents for purposes of verifying the accuracy of any information provided by Merchant and for purposes of accessing and monitoring Merchant's credit status. Merchant authorizes all such credit bureau reporting agencies to release any information they may have pertaining to Merchant to the ORC. This Merchant Application may only be modified as approved in writing by an authorized officer of the ORC/BIZNET Internet Services, Inc.

By agreeing to this Merchant Application, I acknowledge that the above information is correct and that I understand the terms as stated above.