CLIENT APPLICATION DISCLOSURE AGREEMENT

I/We understand that information is given for the purpose of obtaining credit. I/We warrant that all of the information is true. I/We hereby authorize all of the persons or companies on the application to release to Interstate Billing Service, Inc., or its representatives, any information with regard to my/our financial condition, as may reasonably have a bearing on this application. I/We authorize Interstate Billing Service, Inc. to obtain a consumer credit report on my/our personal credit history if necessary, in accordance with the Federal Fair Credit Reporting Act, and to use this report in making decisions concerning my/our credit worthiness.

I/We agree to conduct transactions with Interstate Billing Service, Inc., its successors, assigns, and/or designees, by electronic means, including as appropriate through use and receipt of electronic records and electronic signatures.