Page 1 of 6 RESELLER REGISTRATION FORM. Introducing Sales Person: Branch. Company Information

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1 ENGENUITY (PRIVATE) LIMITED Level 07, BOC Merchant Tower, St Michael's Road, Colombo 3 Tel : , Fax : info@engenuity.lk Introducing Sales Person: RESELLER REGISTRATION FORM Company Information Branch 1 Name of company 2 Company Reg No Date 3 Registered address 4 Telephone Fax 5 6 Web 7 Business address 8 Telephone Fax 9 Company Type Private Ltd Co Public Quoted Public Non Quoted Partnership Sole Proprietorship 10 If this company is a Parent or Subsidy of a company YES NO 11 Business Premises / Property: Leased Owned Rented 12 Business Type Corporate Reseller Retailer Consultant Online Retailer Other 13 Monthly Turnover 14 No of employees Proprietor / Directors Details Proprietor / Director 1 Detail 15 Name 16 NIC / Passport No 17 Percentage of ownership Designation 18 Mobile Telephone address 19 Home Telephone 20 Home Address 21 Other business details if any 22 Name 23 address 24 Have you ever filed for bankruptcy? Yes No 25 If yes, Company name Year Page 1 of 6

2 Director 2 Details 26 Name 27 NIC / Passport No 28 Percentage of ownership Designation 29 Mobile Telephone address 30 Home Telephone 31 Home Address 32 Other business details if any 33 Name 34 address 35 Have you ever filed for bankruptcy? Yes No 36 If yes, Company name Year Director 3 Details 37 Name 38 NIC / Passport No 39 Percentage of ownership Designation 40 Mobile Telephone address 41 Home Telephone 42 Home Address 43 Other business details if any 44 Name 45 address 46 Have you ever filed for bankruptcy? Yes No 47 If yes, Company name Year Operational Contact Details Sales / Marketing contact 49 Name: Designation: 50 Mobile: Telephone Financial contact 51 Name: Designation: 52 Mobile: Telephone Technical/Service Contact 53 Name: Designation: 54 Mobile: Telephone Bank Account Details Bank account 1 55 Bank Name: Branch 56 Account #: 57 Contact Person: 58 Telephone: Fax: ID : Bank account 2 Page 2 of 6

3 59 Bank Name: Branch 60 Account #: 61 Contact Person: 62 Telephone: Fax: ID : Bank account 3 63 Bank Name: Branch 64 Account #: 65 Contact Person: 66 Telephone: Fax: ID : Note : Please attach 3 months bank statements for credit request 67 Is there any pending litigation against the company? Yes No 68 If Yes, give a brief description: 69 Date of legal action taken: Financial statements for the preceding two three (3) months are required for all credit applicants. Financial statements & Bank statements must include balance sheets and income statements. Unqualified financial statements must be certified by the Applicant s Owners/Officers as being true and complete, and prepared in accordance with generally accepted accounting principles. The statements financial periods must be included. Business Reference 1 70 Company: 71 Address: 72 Contact 73 Telephone Fax: 74 Mobile 75 Business Reference 2 76 Company: 77 Address: 78 Contact 79 Telephone Fax: 80 Mobile 81 Business Reference 3 82 Company: 83 Address: 84 Contact 85 Telephone Fax: 86 Mobile 87 Page 3 of 6

4 The undersigned individual hereby irrevocably submits to the non-exclusive jurisdiction of the Courts of Sri Lanka, in any action or proceeding arising out of or relating to the subject matter hereof and hereby The undersigned individual and Applicant each hereby authorize the release of all information needed to verify the contents of this application or to otherwise process this application, including but not limited to contacting third parties concerning the credit-worthiness of the applicant and/or the undersigned. In addition, the undersigned individual hereby consents to ENGENUITY use of a consumer credit department report in order to evaluate such individual s credit worthiness as principal, proprietor, guarantor or the like in connection with the extension of credit as contemplated by this application. RESELLER ACKNOWLEDGEMENT We acknowledge and confirm that: 88 We have answered the questions in this Reseller Application with the correct information That the Company named above is a computer hardware/software reseller That I am an authorized representative for execution of this Agreement. 94 We agree to immediately notify ENGENUITY (PRIVATE) LIMITED of any changes in ownership of our business or any other relevant change in the management/finance area of our business as set forth, herein by registered post to ENGENUITY (PRIVATE) LIMITED LEVEL 16,BOC MERCHANT TOWER, ST MICHAEL'S ROAD, COLOMBO 3 All sales of products and services by ENGENUITY (PRIVATE) LIMITED to the applicant will be at ENGENUITY (PRIVATE) LIMITED s sole discretion. That we agree upon the payment terms set forth by ENGENUITY (PRIVATE) LIMITED, as may be amended from time to time without prior written notice at ENGENUITY (PRIVATE) LIMITED s sole discretion. I / We agrees to notify ENGENUITY (PRIVATE) LIMITED, in writing, of any changes of ownership of its business within fourteen (14) business days..... Signature Rubber Stamp Designation Date..... Signature Rubber Stamp Designation Date..... Signature Rubber Stamp Designation Date Thank you for the interest you have shown in ENGENUITY (PRIVATE) LIMITED. We look forward to working with you. FOR OFFICE USE ONLY APPROVED CREDIT LIMIT: Company Officer Signaturee Officer Name Designation Date Page 4 of 6

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