United Technology - Mainstream Memory Module Manufacturer with Lifetime Warranty

- Memory Modules + Lifetime Warranty -

P.O. Box 8638, Rowland Heights, CA 91748, USA

Phone: (909) 556-3708

e-mail: email@unitedmemory.com

Applicant's Certification & Authorization

Corporate Name:

Other AKA Name(s):

Certification:

The undersigned certifying:

1. I/we have made application to United Technology containing various information provided by me/us. I/We certify that all of the information is true and complete. I/We made no misrepresentation in the application or other documents, nor did I/We omit any pertinent information. 2. I/We understand and agree that United Technology to verify the information provided by me/us with related contacts/parties. 3. I/We fully understand that it is Federal crime punishable by fine or imprisonment, or both, to knowingly make any false statements upon the application.

Authorization to Release Information:

To whom It May Concern:

1. I/we have made application to United Technology. As part of the application process, United Technology may verify information contained in my/our application and in other documents in connection with the application, either before or as part of it's control/audit process. 2. I/We authorize you to provide United Technology any and all information of my/our credit and documentation that they required. 3. A copy of this authorization may be accosted as an original.

Corporate Officer(s)/Partners/Sole Owner:

Name 1:

Title:

Social Security Number:

Signature:

Date:

Name 2:

Title:

Social Security Number:

Signature:

Date:

Bank/Financial Institute Use Only

Bank Information:

Bank Name:

Branch:

Bank Officer Name:

Bank Address: City: State: Zip:

Phone:

Fax:

Customer/Bank Account Information: (The Payment Bank)

Account Name:

Account Type:

Account Number:

Account Opened Date:

Average Balance: (Last 12 months)

Current Balance:

Number(s) of Stop-Payment or NSF: (Last 24 months)

Comments of this Account: (Confidential controlled)

Print Name: (Bank Officer)

Title:

Signature:

Date: