By signing below, I warrant to BLUECUBE, Inc. (“BLUECUBE LIFELINE”) that (1) I am an authorized representative of Applicant, (2) I have full authority to sign this
Dealer Application on behalf of Applicant and (3) to the best of my knowledge all of the information contained in this Dealer Application is true and correct. I agree
to pay all obligations due bluecube for services and products provided by Bluecube. If Bluecube takes action to collect any unpaid balance of Applicant, I agree to
pay the actual attorney fees, costs and expenses incurred, plus interest at the highest rate authorized by law.
Please attach a copy for the following documents to your completed application:
1. Copy of Principal Owner’s Driver’s License
2. Business License (any kind except expired one) or Utility bill which states current business Name and Address