Datalogger_Account_Form.doc



[pic] NEW ACCOUNT – DATA LOGGER PROGRAM

This account application is for new accounts for Lutron Electronics Company

Fill out all sections of this form as completely as possible. Incomplete applications cannot be processed.

Email completed form to salesops@. Questions? Call 1-888-LUTRON1

GENERAL INFORMATION

Business is:

____Corporation ____Proprietorship ____Ltd. Liability Company ____Partnership ____Ltd. Liability Partnership

State of Incorporation/Organization ______________________Date Incorporated/Organized________________

Federal I.D. State Organizational Dun & Bradstreet

Number_______________________ I.D. Number _____________________ Number __________________

Sales tax exemption: Yes____* No____

*If yes, please attach your sales tax exempt certificate made out to Lutron Electronics Co., Inc.

Bill To:

Firm Name: _________________________________________________________Date:____ /______ /_______

Billing

Address: ___________________________________________________________City: ______________________

State ________ Zip Code: _____________ Tel: ____________________________ Fax: _______________________

Accts Payable Contact: ________________________________________________Tel: ______________________

Email Address:_________________________________________________________________________________

Ship To:

Firm Name:____________________________________________________________Attn:______________________

Shipping Address: __________________________________________________City: _____________________

State _______ Zip Code:____________Tel:_____________________________Fax:________________________

COMPANY PROFILE (if privately held): Owners/ Principals

Name: _________________________________________Title: ________________________________________

Tel: ____________________________________________% Ownership _________________________________

Name: __________________________________________Title: _______________________________________

Tel: _____________________________________________% Ownership ________________________________

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Bank Information (attach separate page with additional information, if necessary)

Bank________________________________________ Phone#________________ Fax#__________________

Address_____________________________________ Contact Name_________________________________

_____________________________________ Account # ____________________________________

Has Applicant filed for bankruptcy

in the last five years? __________________If yes, when and where?_________________________________

Applicant applies to Lutron Electronics Co., Inc. (“Lutron”) for the right to make purchases on an open account basis. This Application is not an agreement to extend credit. Lutron may, in its discretion, extend or withdraw credit from time to time. Applicant acknowledges receipt of, and agrees to, Lutron’s Terms and Conditions of Sale. Applicant will pay invoices from Lutron in accordance with the terms established from time to time by Lutron. Applicant agrees to provide Lutron with such financial information, including copies of financial statements and tax returns, as periodically requested by Lutron. Applicant certifies that the information contained in this Application, and in any financial statements and tax returns provided to Lutron, is, or will be at the time of delivery, correct and complete, and may be relied upon by Lutron in extending credit to Applicant. Applicant authorizes Lutron to verify

the information provided above and to obtain such other credit information on Applicant as Lutron deems

appropriate, including independent credit reports and information from its credit references and banks. Applicant

authorizes the credit references and banks to release information to Lutron that may be used to determine credit

worthiness. Applicant agrees to notify Lutron of any allegedly defective product, and of any discrepancy or

question with any invoice or statement of account, received from Lutron within 30 days of receipt and that the

failure to notify Lutron of any such defect, discrepancy or question within such period waives any and all rights to

raise such defect, discrepancy or question at a later time. If disputes arise, Applicant agrees to only withhold

disputed amounts and to only do so until such time as a resolution occurs. Applicant agrees to pay all costs of

collection, including attorneys’ fees, actual out-of-pocket expenses and collection fees incurred by Lutron in

collecting Applicant’s account through a collection agency or attorney. If Lutron files suit to collect the account,

Applicant also agrees to pay interest to Lutron on the past due balance on its account at a rate equal to the lesser

of 12 percent per annum or the maximum rate permitted by applicable law from and after the date that the past

due amounts were payable to Lutron.

DISCLAIMER: Lutron Electronics Co., Inc. (“Lutron”) provides these data logging components (the “Components”) to the loanee (“You”) on a voluntary basis solely for informational use.  Lutron explicitly disclaims any responsibility for: (i) the accuracy of any data procured by or through the Components (the “Data”); (ii) any decisions based upon or relating to the Data; and (iii) any damages or claims of any kind (by You or any third party) relating to the Components or Data.  By accepting these Components, You hereby acknowledge and agree to the terms of this Disclaimer and accept complete responsibility for the Components, Data and any decisions based upon or relating to the Components or Data.  Energy savings arising from Lutron products can only be accurately measured after the proper installation and use of such Lutron products. Applicant agrees that Pennsylvania law governs the interpretation of this Application and that Lutron may bring suit to collect amounts due in Lehigh County, Pennsylvania.

Signature __________________________________ Date ______________________________________

Print Name _________________________________ Title_______________________________________

THE FEDERAL EQUAL CREDIT OPPORTUNITY ACT PROHIBITS CREDITORS FROM DISCRIMINATING

AGAINST CREDIT APPLICANTS ON THE BASIS OF RACE, COLOR, RELIGION, NATIONAL ORIGIN, SEX,

MARITAL STATUS; AGE (PROVIDED THE APPLICANT HAS THE CAPACITY TO ENTER INTO A BINDING

CONTRACT); BECAUSE ALL OR PART OF THE APPLICANT'S INCOME DERIVES FROM ANY PUBLIC

ASSISTANCE PROGRAM; OR BECAUSE THE APPLICANT HAS IN GOOD FAITH EXERCISED ANY RIGHT

UNDER THE CONSUMER CREDIT PROTECTION ACT. THE FEDERAL AGENCY THAT ADMINISTERS

COMPLIANCE WITH THIS LAW CONCERNING THIS CREDITOR IS FEDERAL TRADE COMMISSION, EQUAL

CREDIT OPPORTUNITY, WASHINGTON, D.C. 20580.

DATA LOGGER EQUIPMENT LOAN AGREEMENT

Pursuant to this DATA LOGGER EQUIPMENT LOAN AGREEMENT (“Agreement”), Lutron Electronics Co., Inc. a Pennsylvania corporation (“Lutron”), will loan to the energy savings contractor/agent listed below (“Borrower”) certain of Lutron’s Data Logger equipment (“Equipment”), as set forth herein.

Prior to receiving Equipment, Borrower or Borrower’s Authorized Individual must execute this Agreement.

Borrower assumes full responsibility for all Equipment (including any accessories) in its possession. It is the sole responsibility of the Borrower to return items on-time and in working condition. In the event of theft, loss, or damage to Equipment, Borrower is responsible for all replacement costs for new Equipment of the same or equivalent model.

Upon return of Equipment, Lutron will verify that all Equipment and any accessories are returned in good working condition and are not damaged or missing. If any Equipment is lost, damaged or stolen, Borrower must notify Lutron. The approximate replacement price for each unit of the Equipment is $500. Lutron will keep a log of all loaned Equipment by model and serial number.

By executing this Agreement, Borrower and Authorized Individual hereby acknowledge and agree to the following:

□ I have read and understand the terms and conditions of this Agreement and am authorized to execute this Agreement on behalf of Borrower.

□ I agree that by entering my name in the signature box, I am submitting an electronic signature that qualifies in place of my actual signature.

□ I agree and hereby authorize Lutron to charge Borrower for any and all replacement fees due under this Agreement.

□ I agree that the Equipment at all times remains the sole and exclusive property of Lutron.

□ I agree that all data files resulting from or relating to Borrower’s use of the Equipment are the exclusive property of Lutron and agree to provide a copy of such data files to Lutron upon request.

□ I agree that all Equipment must be returned to Lutron at Borrower’s sole cost and expense. Contact Lutron customer service at 610-282-3800 to get information about how to return through Lutron’s RGA process.

□ I agree that I must have an account setup with Lutron prior to being loaned any Equipment. Contact your local Lutron sales representative for more information.

□ I agree that Lutron does not provide replacement batteries. Batteries are rated for 1 year lifetime.

|COMPANY INFORMATION |PAYMENT INFORMATION |

|Company Name |Company Name |

|Address |Billing Address |

|City / State / ZIP |City / State / ZIP |

|Name of Authorized Individual |Name of Department / Individual to be Billed |

|Email Address |Email Address |

|Phone / Fax |Phone / Fax |

|Authorized Individual Signature: |

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