Hardware Auction

CUSTOMER RECORD FORM

All fields and questions must be completed before an invoice can be created. If information cannot be provided, please write an explanation of why. If a section or question does not apply, enter ‘N/A’ but do not leave blank.

If any of the companies listed below are located outside of the United States, please provide a copy of the applicable Principals passport so that the “Know Your Customer” checks can be performed without delay. If a flag is reported on a company principal and a photo of their passport has not already been supplied, one must be provided before invoicing can occur.

If you plan to send funds from a 3rd party account different from the entity below, you must complete a separate Customer Record for the company sending payment.

SOLD TO (Legal entity)

Company Name (Legal Entity)

Street Address

City/State/Province

Country

Principals (Name & Title)

Contact Name

Contact Email

Contact Phone #

SHIP TO (if not 'SOLD TO')

Company Name (Legal Entity)

Street Address

City/State/Province

Country

Contact Name

Contact Email

Contact Phone #

bill to (if not 'sold to')

Company Name (Legal Entity)

Street Address

City/State/Province

Country

Contact Name

Contact Email

Contact Phone #

* If Apto Solutions is shipping assets to a facility in Georgia, California, or Texas, the PURCHASER’S BLANKET RESALE EXEMPTION CERTIFICATE on page 4 must be completed and a copy of your resale certificate provided with the submission of this form.

DOING BUSINESS AS, OR ALSO KNOWN AS NAME, IF USING A TRADE STYLE

Company Name

Street Address

City/State/Province

Country

business details

If Other, please specify.

Briefly describe the nature of your business.

D&B/Trade Registry or Other Reference Number

Year Established

Place Established

accounts payable point of contact

Name

Street Address

City/State/Province

Phone Number

The below is considered a signature and indicative of agreement with the certification and letter of assurance.

We understand that Apto Solutions, Inc. and/or any of its affiliated or subsidiary companies (“Apto Solutions”) may provide us with hardware, software, and/or technology (“Product(s)”), that may be subject to the export laws and regulations of the United States and other nations. We also understand that, under these export control laws and regulations, Apto Solutions’s delivery of Product(s) to us may take place only after Apto Solutions has received written assurance from us. Accordingly, we hereby agree: ▪ that we will not transfer, export, or re-export, directly or indirectly, any Product(s) acquired from Apto Solutions to Afghanistan, Burma, Central African Republic, (Democratic Republic of) Congo, Russia, Somalia, and Venezuela, or any nationals thereof, or to any other country subject to restriction under applicable laws and regulations, and that we are not located in, under the control of, or a national or resident of any such country; ▪ that we will not use the Product(s) in any activity related to the development, production, use, or maintenance of Weapons of Mass Destruction, as defined by the U.S. Dept. of Commerce, including without limitation, uses related to nuclear, missile, and/or chemical/biological development and or production and that we will not transfer, export, or re-export, directly or indirectly to any party engaged in any such activity; if we are engaged in the development or production of Weapons of Mass Destruction, we acknowledge that we could be subject to and responsible for U.S. export licensing requirements; ▪ that we will not transfer, export, or re-export, directly or indirectly to any party listed by the U.S. Government or under any applicable law as prohibited from receiving Product(s) and that we are not on, or under control of anybody on, any such list; ▪ that we will comply with all applicable laws and regulations, including all environmental laws, directives and regulations, whenever we transfer, export, or re-export Product(s) obtained from Apto Solutions; ▪ that we will not request or make any regulatory certifications or applications on behalf of Apto Solutions and; if changes to this Letter of Assurance are necessary, we will contact Apto Solutions for approval at ar@aptosolutions.com.

Name of Authorized Representative

Title

Date