BioBase Customer Account Application for the Purchase of BioBase-Compatible Hardware

ORGANIZATION/CUSTOMER INFORMATION

Organization Name *

d/b/a (if applicable)

Billing Address *

City *

State/Province *

Zip/Postal Code *

Country *

Shipping Address (if different than Billing Address)

City

State/Province

Zip/Postal Code

Country

Organization Email Address *

Phone Number *

Fax Number

Organization Contact Name (for all mailings) *

Contact Phone *

Contact Email *

UNIFORM SALES & USE TAX

MULTIJURISDICTION

Each new customer is required to submit their sales tax exemption or resale certificate number. This exemption is exclusively for the Navico customer. The issuer and the recipient have the

responsibility of determining the proper use of this certificate under applicable laws in each state, as these may change from time to time.

Issued to Seller: Navico, 4500 S 129^th E Ave, Ste 200, Tulsa OK 74134-5885

Are you requesting to be sales tax exempt? *

Yes

No

Are you attaching your state issued tax exempt certificate? *

Yes

No (complete the below fields)

Attach your Tax Certificate(s) here for all states
in which you are registered. *

I certify that the Organization listed above is lawfully organized as a (select one Type of Organization below), and further certify that the information entered herein is correct and, if applicable, the tax-exempt organization is recognized as valid by the status or US territory in which it is enrolled.

Description of Organization:

General description of tangible property of taxable services to be purchased from the seller:

State/Province: Select the state for which you are registered.
If you see a number beside the selected state, click here
Uniform Sales & Use Tax Certificate
for an explanation specific to that state. *

State Registration, Seller's Permit, or ID Number of Purchaser *

Are you registered in another state? *

Yes

No

State/Province: Select the state for which you are registered.
If you see a number beside the selected state, click here
Uniform Sales & Use Tax Certificate
for an explanation specific to that state.

State Registration, Seller's Permit, or ID Number of Purchaser *

Are you registered in another state? *

Yes

No

State/Province: Select the state for which you are registered.
If you see a number beside the selected state, click here
Uniform Sales & Use Tax Certificate
for an explanation specific to that state.

State Registration, Seller's Permit, or ID Number of Purchaser *

Are you registered in another state? *

Yes

No

State/Province: Select the state for which you are registered.
If you see a number beside the selected state, click here
Uniform Sales & Use Tax Certificate
for an explanation specific to that state.

State Registration, Seller's Permit, or ID Number of Purchaser *

Are you registered in another state? *

Yes

No

State/Province: Select the state for which you are registered.
If you see a number beside the selected state, click here
Uniform Sales & Use Tax Certificate
for an explanation specific to that state.

State Registration, Seller's Permit, or ID Number of Purchaser *

I further certify that if any property so purchased tax free is used or consumed by the firm as to make it subject to a Sales or Use Tax we will pay the tax due directly to the proper taxing authority when state law so provides or inform the seller for added tax billing. This certificate shall be a part of each order which we may hereafter give to you, unless otherwise specified, and shall be valid until cancelled by us in writing or revoked by the city or state.

Under penalties of perjury, I swear or affirm that the information of this form is true and correct as to every material matter.

Authorized Signature (Owner, Partner or Corporate Officer) *

clear

Printed Name *

Title *

Date * +

TYPE OF ORGANIZATION

Describe your Organization's purpose (e.g. the study of aquatic ecosystems): *

0/255 characters

NAVICO CUSTOMER PORTAL ACCESS

The Navico Customer Portal is your one-stop shop for Service, Sales and Marketing. This resource will provide 24/7 access to reseller reference and support materials and tools. The Customer Portal is a centralized information hub, requiring each user to only login once with a single username and password, and it will offer access to Orders, Account/Credit Status, System Builder, Certification Status, RMA Request Function, Link Pro App, NIF File Viewer and Vessel Look Up, depending on your assigned login credentials.

Please provide information for individual within your organization whom you would like to access our Customer Portal. Login credentials will be assigned based on the information provided.

Name *

Title *

Contact Phone *

Contact Email *

Type of Access

Place Orders (Purchase)

By submitting this form, the undersigned hereby agrees that any products ordered through the Navico Customer Portal are for end-use only and are not for resale. *

Yes

No

SIGNATURES

BIOBASE CUSTOMER ACKNOWLEDGEMENT: By signing below, you confirm that you have read and agree to the BioBase Terms and Conditions found here.

Organization Signature *

clear

Printed Name *

Title *

Date * +

I agree to be bound by the BioBase Terms and Conditions. *

Yes

No