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I understand that Amgraf, Inc. will verify the accuracy of this information by contacting the references listed above. I also certify that I have

read and understand the Amgraf, Inc. Void Pantograph End User License Agreement.

Your Name

Title

COMPANY

TELEPHONE

ADDRESS

APPLICATION DATE:

Amgraf's proprietary security technology is available only to reputable document producers who have a legitimate need to

manufacture secure documents for lawful customers. To protect against unauthorized usage of our technology, we perform

a background check before licenses are granted. The undersigned guarantees that the information below is correct and

complete and authorizes Amgraf to conduct any background investigation needed for verification of such.

Name of Business

Sole

Partnership

Corporation

Products and/or Services Produced at this Location

Street Address

City

Zip/Postal

Billing Address (If Different)

Telephone

FAX #

Name of Chief Executive Officer

Telephone

Name of Pre-Press Department Manager

Please explain what security technology you need, how it will be used, and what safeguards you will follow to keep the

technology from being misused, pirated, lost, or stolen.

Optional: List suppliers with whom you have maintained a business relationship for a minimum of one year.

Date Business Started

APPLICATION TO LICENSE AMGRAF SECURITY TECHNOLOGY

Extension

Zip/Postal

Telephone

Extension
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Web Site Address

ASSOCIATION NAME

ADDRESS

TELEPHONE

Optional: List trade associations that your company is affiliated with.

Rest assured, we do not sell your nonpublic personal information to others.

Amgraf will contact you with your login and password as soon as we complete the Registration process.

State/Prov./Region

City

State/Prov./Region

E-Mail Address

All Yellow Fields are Required

Re-Enter E-Mail Address

Country

Country

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