Pitney Bowes/Mayor/DOLSTATE AND LOCAL GOVERNMENT TERM RENTAL AGREEMENT
Your Business Information
FULL LEGAL NAME OF RENTER "/' / ' '
BILLINGADDRESS/'
PHONE # , /
EQUIPMENT LOCATION (IF NOT SAME AS ABOVE)
CAN #
· -, ~ ,: OBA NAME
,/~' / CONTACT NAME
CI1~'
ORDER #
I EMAILADDRESS
; / ~ , i STATE
.,- !j~E, ND INVOICE TO A13'N OF
STATE ZIP+4
CREDIT CARD # EXP DATE
NAMEONCARD
TYPE
TAXEXEMPT#
SALES TAX (IF APPLICABLE)
FISCAL PERIOD FROM TO RENTER PO #
Your Business Needs
Modd _r~-~ ~d~en~ & Serm~ Oe~fp~o~ ~o,~ ~ ~ F~ ~,~ ~ ~,~
//'l! . , ~ : ' ,
~::-; --,: , ./ , ,-
[] Equipment Maintenance Aga'eemeet On Rental
F3 Soft, Guard Agreemeat
L3 Soffiarare Mabteeaaee Agreemenl
[] MeterOe~eatal
Payment Schedule I Billing
Your Payment Plan
Initial Rental Term:
Frequency F~ Monthly E] Quarterly Lr Other (specify__)
Rrst / ,, monff,~ $ '. ,/, (fl~ ~enth
Next months $ per month
Next months $ per month
Rna[ Payment $ 100.00
Initial Check Amount $
SIGNATURE
PRINT NAME
PB ACCOUNT REP NAME. ' , ,~, ,; =' ', ,'' ' -
Rental Tenns and Conditions
By your signature as "Rerder' below, you request that We rent th you the equipment described abmrb'~ '
Agreement, all payments set forth in the Payment SChedule shall be referred to as the "Total Pa~t~
referred to in the Payment SChedule other than the "Rnal Payment" shall be referred to singularly as a
and collectively as the 'Pedod Payments·" Your offer will be binding on us when we accept it by having an authorized
employee sign ri. All payments hereunder shall be payable only to Us at our execufive Offices Unless we direct you
otherwise in Writing.
1. NON-APPROPRIATION. YOU Warrant that you have fueds available to pay the Total Payments until the end o1 your
currenl fiscal pedod, and shall use your best efforts to obtain funds to pay the Total Payments in each subsequent fiscal
period through the end of year Initial Term. If your appmpriafion request to your tsgislafive body, or funding autbediy
("Governing BOdy") for funds to pay the Total Payments is denied, you may terminate this Agreement on the last day of the
fiscal period for which funds have been appropriathri, upon (i) submission of documentation reasonably satisfactory to us
evidencing the Governing Body's denial of an appropriaUon sufficient to continue this Agreement for the next succeeding
fiscal period, and (ii) satisfaction of all charges and obligations under this Agreement incurreri through the end of the fiscal
periOd for which funds have been appropriated. including the rntum of the Equipment at your expense,
TITLE : , /
DATE
EMPLOYEE # }" /-/· DISTRICT NAME & #
TITLE DATE
/
PB ACCEPTED BY
EXECUTIVE OFFICE.' 27 WATERVIEW DR · SHELTON, CT 06484-4361 · EGUIPMENT VENDOR: PITNEY BOWES, INC. ° FOR SALES AND SERVICE CALL 1-800-322-8000
WHITE COPY PBCC ° PINK COPY RTNEY BOWES INC. · YELLOW GOPY CUSTOMER
PAGE 1
SEE PAGE 2~:OBADIlrrintsAI TEI~4S AND CONDITIONS
IN WITNESS WHEREOF, the parties hereto have made and executed this Agreement as follows:
CITY OF CARMEL, INDIANA
by and through its Board of Public
Works and Safety
PimeyBowes
By:
ATTEST:
By:
Authorized Signa~e
Printed Name
FID/SSN:
D ate: ¢//tq ,Z, '
Date: