The Escrow Company Beneficiary Registration Form

Depositor Company Name

Software Escrow Agreement Number

Name of Authorised Representative of Depositor Completing this Form

Depositor Representative Email Address

Depositor Contact Telephone Number

schedule authority legal

Beneficiary Registered Company Name

Beneficiary Company Number (if applicable)

Beneficiary Registered Address (Street and Number)

Beneficiary Registered Address (City)

Beneficiary Registered Address (Post Code / ZIP Code)

Beneficiary Country

Beneficiary Contact Person

First

Last

Beneficiary Position in Company

Beneficiary Contact Email Address

Beneficiary Phone Number

Beneficiary email address for legal notices sent under the agreement?

Product Name

Deposit Materials to be included within this Agreement

Source Code and Documentation
Database(s)
Access Credentials

Product Modules Licensed to the Beneficiary (if relevant)

Do you intend to deposit customised Source Code for this Beneficiary?

Module Name

Module Tag

Repo URL (if relevant)

Module Name

Module Tag

Repo URL (if relevant)

Module Name

Module Tag

Repo URL (if relevant)

Would the Beneficiary like verification testing to be performed on the Source Materials?

Note to include specific to this Beneficiary

By clicking “Submit”, and submitting this Beneficiary Registration Form, you: (1)Authorise the registration of the Beneficiary identified above under the relevant Software Escrow Agreement referenced in this form; (2)Confirm that you have full authority to register the Beneficiary and to bind the Depositor to the terms of that Agreement; (3)Consent to the collection, storage and processing of the information submitted in this form by The Escrow Company for the purposes of administering and performing the Software Escrow Agreement, in accordance with its Privacy Policy.

Confirmed
Declined

The Escrow Company Beneficiary Registration Form

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