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APPLICATION TERMS AND CONDITIONS:

IF YOU ARE AN EXISTING LESSEE WHO NEEDS TO MAKE A MODIFICATION TO THE AGREEMENT USE, PROPERTY SIZE, TERM, OR REDUCTIONS, USE THIS APPLICATION TO SUBMIT YOUR REQUEST.

NOTICE: ADDING NEW UTILITY LINES TO AN EXISTING AGREEMENT WILL REQUIRE A NEW UTILITY APPLICATION, NOT A MODIFICATION. CHANGES TO OWNERSHIP WILL REQUIRE AN ASSIGNMENT APPLICATION, NOT A MODIFICATION.

Complete application package will include completion of all applicable fields, engineer stamped plans, certificate of insurance and confirmation of payment. Incomplete applications, including missing information in required fields, may result in processing delays. Applications submitted without the required fees will not be processed.

Please note, if the submitted application and plans require review by any independent environmental (HAZMAT) or other outside consultants, this review will be at applicant’s sole cost and in addition to the aforementioned fees.

***Canadian residents/businesses, this fee is a taxable supply, please include applicable GST***

STANDARD APPLICATION PROCESS IS 60-90 DAYS DEPENDING UPON THE COMPLEXITY OF THE APPLICATION. REQUEST FOR RUSH SERVICE: Once a COMPLETE application and required fees are received, including the rush fee of $1,500 USD ($1,903 CAD), a draft agreement will be made available for review within twenty-one (21) business days, assuming submission of completed application. Please be sure to mark the RUSH box below for projects requiring expedited review.

If the application is approved, the applicant agrees to reimburse property owner for any cost incurred by property owner incident to installation, maintenance, and/or supervision necessitated by this installation and further agrees to assume all liability for accidents or injuries which arise as a result of this installation as provided in the agreement to be executed. In addition, annual fees will be assessed pursuant to a written lease agreement.

Once an executable agreement is submitted to you, this agreement must be fully negotiated and executed within thirty (30) days. If not executed, the application and materials will be archived, and resubmission (including fees) will be required.

PLEASE INITIAL HERE INDICATING YOUR UNDERSTANDING OF THIS POLICY :

Upon submission of your application you will be provided with an opportunity number, please ensure to reference the opportunity number on the method of payment to ensure proper allocation. Send payment for the non-refundable fee of $1,000 USD ($1,403.43 CAD) to:

OmniTRAX Holdings Combined, Inc.
PO Box 209979
Dallas, TX 75320-9979

	RUSH
Check the box if this is a RUSH application. Add $1,500 USD ($1,903 CAD) in addition to the application fee listed above.

Provide Check Number :

CERTIFICATE OF INSURANCE

Upon submission of your application, you are required to submit a Certificate of Insurance. In addition, you will be required to obtain a CG 24 17 10 endorsement. Please ensure to name the Railroad as the Certificate Holder and that all required coverages are evidenced. Please review the templates for Certificate of Insurance and CG 24 17 10 Endorsement, linked here.

Railroad (Certificate Holder)

RR Acronym

RR Record ID

Please attach the Certificate of Insurance, including all required coverages and naming the selected Certificate Holder

Account Information

Section 1 - Customer Account Information (Complete this section on behalf of the Agreement Entity and include information as it would be listed in the Agreement) :

Account Information

Is this application for a new customer account or an existing customer account?

Mailing Account Information :

Account Name :

Type of Account (please select one):

Federal Tax Identification number (U.S. Leases):

Mailing Street :

Mailing City :

Mailing State :

Mailing Zip Code :

Account Contact First Name :

Account Contact Last Name :

Account Contact Title :

Account Contact Email :

Account Contact Phone :

If applicable, State/Province of incorporation or organization :

Email Address Where Notices Can be Sent to :

Overnight Delivery Service Address (if different) :

Application Status

Source of Opportunity

Billing Account Information(Complete this section on behalf of the entity responsible for annual Agreement payments) :

Same as Mailing Account :

YesNo

New Billing Account Information :

Billing Account Name :

Billing Contact First Name :

Billing Contact Last Name :

Billing Phone Number :

Billing Street :

Billing City :

Billing State :

Billing Zip Code :

ABV. APP TYPE

Billing Email :

Billing Account Information Same as Mailing Account :

Billing Account Name :

Billing Street :

Billing City :

Billing State :

Billing Zip Code :

Billing Contact First Name :

Billing Contact Last Name :

Billing Phone Number :

Billing Email :

Section 2 - Application Location Details

Nearest Milepost :

DOT No. :

Subdivision :

Track Station (from) :

Track Station (to) :

Section :

Township :

Range :

Property Address/Street :

Property City :

Property County :

Property State or Province :

Property Country :

Opportunity Currency :

Geographical Coordinates Required (Decimal Degrees DD):

Property Coordinate (Latitude) :

Property Coordinate (Longitude) :

Located on the (N/S/E/W) side of (landmark, intersection) :

Existing Lease Number or Name :

Do you plan to sublease to another party? (NOTE: If yes, additional information will be required.)

Please provide additional information :

Section 3 - Purpose of Modification :

Application Type - Modification (Customer Request) API Name :

Agreement Type :

Product Category

Product Sub-Category

Purpose of Modification (Detailed description of the intended modifications to the existing agreement) :

For modifications adding new Utilities, please end this application and proceed with a new Utility application.

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