Inmarsat Subscriber Application Service Agreement (03/2013)
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Inmarsat Subscriber Application Service Agreement .coredownload Subscriber Application and Services Agreement
Print clearly and complete all sections that apply Return to Inmarsat when complete (details on page 3)
A: Type of applicant (mandatory - must be completed by all applicants)
Individual Corporation
Dealer Charitable/Non-profit
Distributor
Government Agency
Inmarsat Service Provider Please provide ISP Code ____________
B: Services requested (mandatory - must be completed by all applicants)
Mobile, on-demand satellite services
Inmarsat Fleet 77
Inmarsat FleetBroadband
Inmarsat Fleet 55
Inmarsat C
Inmarsat Fleet 33
Other _____________
BGAN Inmarsat Handheld
Inmarsat SwiftBroadband Inmarsat Swift 64
AmosConnect
Iridium®
Iridium OpenPort
Other ____________
Fixed, full period satellite services
ITek®
VSAT
Maintenance
BGAN M2M
Spare Parts
SCPC
Microwave Circuits (Gulf of Mexico Only) IsatData Pro Other ____________
Telephone services Telephone Services
Equipment purchase/rental
Mobile, on-demand satellite services equipment Fixed, full period satellite services equipment
For Inmarsat terminals only select one The terminal will be used exclusively in the United States under Inmarsat's licenses. The terminal will not be used in the United States
C: Corporate applicant information (DO NOT complete if individual applicant)
Company Information (mandatory)
Full Legal Name:
Operating as (trade style):
Duns number (If known): ___________________________
Tax ID Number or Exemption Certificate (attach copy):
Department (If applicable):
Accounts Payable contact:
Ext.: _____________
Invoices Mailed to:
City:
State/Province:
Country:
Zip/Postal Code:
Physical address (if different from mailing):
City:
State/Province:
Country:
Zip/Postal Code:
Country & City Codes & Tel.#:
Fax #:
Company e-mail address:
Website:
Company employee(s) authorized to access call data: ____________________________________________________________
Business Structure (mandatory)
Limited Liability
Partnership
Proprietorship
Division/Subsidiary/Branch Provide parent company name and location:
In business since: __________
Joint venture. Since:
Page 1 of 3
Revised: February 2013
Subscriber Application and Services Agreement
Print clearly and complete all sections that apply Return to Inmarsat when complete (details on page 3)
C: Corporate applicant information (continued)
Senior officers (Responsible for Business Transactions)
Name
Title
President
Vice-President
Chief Financial Officer or Treasurer
Telephone number
Bank reference (Primary Bank Your Company Does Business With)
Name of bank:
Street address: _____________________
Contact person:
Email: Telephone #:
Email:
Branch #:
ABA/Transit #:
Location: ____________________ Fax #:
Account #:
Industry credit references (Minimum of Three Required) 1. Firm Name and Address:
Contact Name: Telephone Number: 2. Firm Name and Address: Contact Name: Telephone Number: 3. Firm Name and Address: Contact Name: Telephone Number:
Email: Fax Number:
Email: Fax Number:
Email: Fax Number:
D: Individual applicant account information (DO NOT complete if corporate applicant)
Applicant Name: Social Security or Social Insurance # (optional):
Date of birth ______/_______/_______ (DD/MM/YY)
Mother's Maiden Name (for security purposes): Full mailing Address: City: Country: Home address (if different from mailing):
State/Prov.: Zip/Postal Code:
City:
State/Prov.:
Country: Home Area Code & Telephone #: Mobile Telephone #:
Zip/Postal Code: Fax #: E-mail address:
Name & Address of Employer:
Position:
Years/months there:
Business Telephone #:
Ext.:
E: Corporate or individual applicant credit card information
Credit card information required for all personal/individual accounts.
Company Credit Card
Individual Credit Card
Type of Credit Card: Card number: Name on card:
Visa
Mastercard
Expiry Date ______/_______ (mm/yy)
Page 2 of 3
Revised: February 2013
Subscriber Application and Services Agreement
Print clearly and complete all sections that apply Return to Inmarsat when complete (details on page 3)
Credit Card for billing purposes only
Credit Card for credit guarantee purposes only
I hereby authorize the use of my card for the above mentioned purposes:
Cardholder signature: _____________________________________
F: Credit terms applied for (mandatory -- must be completed by all applicants)
COD
30 Days
Prepaid
Equipment:
Airtime:
Monthly Credit Desired (Required)*:
Electronic (PDF) Billing. Email Address:
Note: Electronic (PDF) Billing is required for Iridium and other select services
Include special invoicing instructions:
* Notwithstanding approval of the desired credit line, Applicant will be liable for any and all actual costs incurred for use of services and/or equipment provided by Inmarsat.
G: Marketing information (optional for Inmarsat internal use only)
Charitable
Aviation
Fishing
Military
Mining
Oil and Gas
Other
Government Transport
Marine Media
H: Confirmation of information accuracy and release of authority to verify
I hereby certify that I am, or I am duly authorized by, the Applicant (as defined above) and the information in this application and agreement is correct and agree that a facsimile copy hereof will be valid and binding for all purposes. In order to assist Inmarsat or its affiliates (collectively, "Inmarsat") in establishing a line of credit, I authorize (i) the references listed herein to release information requested by Inmarsat, and (ii) Inmarsat to obtain credit reports and other documentation from third parties. In addition, for billing and other Services and/or Equipment purposes, I also herein give Inmarsat consent to transfer my personal data to Inmarsat, as necessary. I understand that Inmarsat's acceptance of this application is contingent upon Inmarsat's satisfaction with the credit review, and that Inmarsat may terminate service without further notice within thirty (30) days of this application if Inmarsat is not satisfied with my credit. I further understand that, except as otherwise agreed by Inmarsat, the Services and/or Equipment requested in Section B, will be provided by Inmarsat pursuant to the applicable Inmarsat terms and conditions posted on Inmarsat's website at www.stratosglobal.com ("Terms") and at the prices provided to Applicant by Inmarsat ("Prices"). Applicant agrees to be bound by the Terms and Prices (each as amended by Inmarsat from time to time) applicable at the time of provision of Services and/or Equipment, unless Applicant executes a separate written agreement with Inmarsat for the Services and/or Equipment. If so, Applicant's use of the Services and/or Equipment will be subject to the terms and conditions, including price(s), of such agreement. Applicant has been provided ample opportunity to review the Terms. Applicant takes particular notice that the Terms include specific clauses including, but not limited to: (A) LIMITATION OF LIABILITY; (B) LIMITATION OF IMPLIED OR STATUTORY WARRANTIES; (C) INDEMNITY, HOLD HARMLESS, AND DEFENSE OF THE PARTIES; AND (D) ARBITRATION, and certifies that such clauses have been brought to Applicant's attention.
Authorized Name (please print):
Agent Name (if applicable):
Authorized Signature:
Agent Signature:
Date (dd/mm/yy):
Date (dd/mm/yy):
Please return completed form to:
St.John's, Newfoundland
Phone: +1 709 754 5400
Fax:
+1 709 748 5300
London, England Phone: +44 20 7993 3340
Lafayette, Louisiana Phone: +1 337 761 2000 Fax: +1 337 761 1284
Houston, Texas Phone: +1 832 463 2100 Fax: +1 832 461 4007
For Inmarsat internal use only:
Bethesda, Maryland
Plantation, Florida
Ottawa, Ontario
Phone: +1 301 214 8800 Phone: +1 954 370 1698 Phone: +1 613 230 4544
Fax: +1 301 214 2234 Fax: +1 954 370 6144 Fax: +1 613 230 4212
Hong Kong
The Hague, Netherlands Singapore
Phone: +852 2918 8215 Phone : +31 70 301 3200 Phone : +852 2918 8215
Fax: +852 2918 9808 Fax : 31 70 343 4796
Fax : 65 6438 6101
Account Manager:
Date (dd/mm/yy):
Account # assigned:
Credit approval:
Date (dd/mm/yy):
Approved credit line $:
Page 3 of 3
Revised: February 2013
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