Skrill Merchant Services Application Form

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1 Skrill Merchant Services Applicatin Frm Skrill Merchant Services Applicatin Frm (the Applicatin ) shuld be signed by r n behalf f the Merchant. It is very imprtant that the Merchant has read the Applicatin and the declaratins set ut within in cnjunctin with the Agreement (as defined in the Declaratins sectin belw) befre signing. By signing the Applicatin, yu are cnfirming that the details prvided within are crrect and that yu have read, understd and agreed t be bund by the terms f the Agreement. Cmpany prfile PLEASE COMPLETE IN BLOCK CAPITALS AND ANSWER ALL QUESTIONS Business Type: Crpratin (Inc.) Limited Liability Cmpany (LLC) Limited Liability Partnership (LLP) Limited Partnership (LP) Sle Prprietr Partnership Publicly Traded Cmpany Charity / Nnprfit Trust Other (Please specify): Cmpany name (Full Legal Name): Ding Business As (DBA) (if applicable): Existing Skrill Custmer ID (if applicable) Principal Place f Business: Street (name and number): City: State: ZIP Cde: Cmpany Registered Address (If different frm abve): Street (name and number): City: State: ZIP Cde: Name f Accunt hlder: Psitin in Cmpany: Address: Telephne Number: Website Address(es)- yur cmpany will prcess thrugh (If the website is under cnstructin please prvide the URL and test site) Cardhlder Statement Trading Name yu wuld like t appear n the cardhlder statement: Cmpany Registratin number (if applicable): Date f Incrpratin/Registratin: Cmpany cmmenced trading date: Federal Emplyer Identificatin Number (FEIN): State f Incrpratin/Registratin: If member f trade assciatin please prvide name and membership number: Skrill USA, Inc. is registered with FinCEN as a Mney Services Business (MSB) and is a licensed mney transmitter, as required by varius state laws.

2 Business Prfile Internet/E-Cmmerce: % Virtual Terminal (MOTO): % = 100% f Card Sales (actual r prjected) Please fully describe the exact nature f yur business and specifically what card payments will be taken fr: Annual cmpany turnver Annual Turnver thrugh the current prvider Prjected Annual Turnver thrugh Skrill Average Transactin Value Current Acquirer Current PSP Prvider / shp system platfrm Current split f transactin (up t 100%) Dmestic (USA) % Eurpe % ROW please specify % Online payment methds accepted (Up t 100%) Visa Credit % MasterCard Credit % Visa Debit, including Visa Business Debit & Electrn % MasterCard Debit, including MasterCard Business Debit & Maestr % American Express % Discver % Other (please specify): % Is yur business seasnal? N Q1 Q2 Q3 Q4 The percentage f sales per quarter: % % % % D yu accept depsits prir t the supply f gds r services please specify: N The size f the depsit paid in advance, e.g. percentage f ttal transactin value: % The average time, in advance f delivery f gds/services, that depsits are taken: D yu accept full payment prir t the supply f gds r services please specify: N The size f the depsit paid in advance, e.g. percentage f ttal transactin value: % The average time, in advance f delivery f gds/services, that depsits are taken: If mre than ne service prvided with differing pre-payment times please cnfirm split f card turnver and details f pre-payment: Descriptin f service/gds sld: Descriptin f service/gds sld: Descriptin f service/gds sld: Descriptin f service/gds sld: Level f card turnver: % Level f card turnver: % Level f card turnver: % Level f card turnver: % Nte: All splits f card turnver shuld ttal 100% Skrill USA, Inc. is registered with FinCEN as a Mney Services Business (MSB) and is a licensed mney transmitter, as required by varius state laws.

3 WARRANTIES/GUARANTEES D yu take payments fr any guarantees r extended warranties (excluding manufacturing warranties)? N The average length f any guarantees/warranties sld: The average percentage f gds returned whilst under guarantee/warranty: Mnths % What is yur refund plicy? D yu take r plan t take payments fr subscriptins r memberships by card: N Please specify all membership/subscriptin ptins, length f time and percentage taken n cards. Percentage f card turnver relating t subscriptins/memberships: Length f subscriptins/memberships and percentage taken n cards: mnths % taken n cards % mnths mnths % taken n cards % taken n cards Des the Cardhlder billing invlve autmatic renewals r recurring transactins: N If Cardhlder must separately cnfirm that they accept that their card will be used fr Recurring Transactins. D yu perate any affiliate prgrams? Are they invlved in the prcessing n yur website? N Please specify Please specify if any lcal r internatinal regulatin applies t yur business mdel N Please specify Please prvide an rganizatinal chart shwing all cmpanies in the grup This chart shuld demnstrate the wnership structure Skrill USA, Inc. is registered with FinCEN as a Mney Services Business (MSB) and is a licensed mney transmitter, as required by varius state laws.

4 Cmpany Directrs Depending n yur business type we require the fllwing Principals t cmplete this sectin: in the case f a sle prprietr, the sle prprietr; in the case f a partnership, all partners; in the case f a Limited Partnership, the general partner; in the case f a Crpratin r LLC, all directrs/members. Directr # 1 Directr # 2 Directr # 3 Directr # 4 First Name Other Names: Last Name: Date f Birth Address: Phne Number: Current hme address: Street name, N: City: ZIP: Cuntry: Natinality: Passprt Number: Ultimate Beneficial Owner Please cnfirm the Ultimate Beneficial Owners. Fr trusts all parties with beneficial vting rights will need t be identified. Sharehlders will be classified as beneficial if they hld 25% r mre f the ttal share r vting rights. If the beneficial wner f a cmpany is anther cmpany r legal entity we will require an explanatin t identify a natural persn/s as beneficial wner. Beneficial Owner # 1 Beneficial Owner # 2 Beneficial Owner # 3 Beneficial Owner # 4 First Name Other Names Last Name: Date f Birth Address: Phne Number: Current hme address: Street name, N: City: ZIP: Cuntry: Passprt Number: Natinality: % Ownership: Mnetary Value f an individual share: Skrill USA, Inc. is registered with FinCEN as a Mney Services Business (MSB) and is a licensed mney transmitter, as required by varius state laws.

5 Supprting infrmatin fr applicatin The fllwing infrmatin is mandatry fr all applicatins: Last six mnths merchant statements (12 mnths if seasnal). Due Diligence Dcumentatin Required Pht ID f Cmpany Representative registered n the Accunt. The dcument must be in clr, (Passprt, State issued ID and Drivers Licence ONLY). Frnt and back f any card used fr ID verificatin r duble page f the passprt. Prf f Cmpany Address (P.O. bx address is nt accepted) either a utility bill r bank statement nly, nt lder than 3 mnths; r any fficial dcument that als includes the address i.e. Certificate f Incrpratin r a Certificate f Incumbency etc. Cmpany Dcumentatin Required Certificate f Incrpratin / Organizatin and/r State business license. If the accunt hlder is any ther than a cmpany directr r a beneficial wner, the latter will need t cnfirm in writing the name f the persn respnsible fr the administratin f the accunt. The cmpany will have t maintain at least ne (1) directr wh is dmiciled in the place f the cmpany incrpratin and registered address. Fr regulated businesses that require any frm f authrisatin dcument, a cpy f the authrisatin dcument needs t be submitted. In certain cases a legal pinin f the business mdel may be requested, The fllwing infrmatin is required if Annual Sales Vlume exceeds 100,000: 1 Year Business Tax Returns. If business has been trading fr less than a year, 3 mnths business bank statements may be used as an alternative. Please return t Or mail t 61 Bradway, Suite 1603 New Yrk, NY USA Declaratins MERCHANT DECLARATION Wrds and expressins used in this Applicatin will, unless therwise defined in this Applicatin, have the same meaning as set ut in the Terms and Cnditins. By signing this Applicatin yu are: 1. Cnfirming that yu are duly authrized t sign n behalf f the Merchant and n cnsent r apprval is required frm any ther persn. 2. Acknwledging that in certain circumstances Transactins may be charged back t yu, and that yu accept the risk f any such Chargeback s. 3. Agreeing that yu will cmply with the Payment Card Industry Data Security Standards (PCI DSS). 4. Cnfirming that yu understand that an Authrizatin Cde is nt a guarantee f payment, particularly where the Cardhlder r Card was nt present when the Transactin was undertaken. 5. Cnfirming that the infrmatin yu have prvided in this Applicatin is accurate and crrectly reflects the gds and/r services ffered by yur business and the Payment Services yu wish t receive. Yu further cnfirm and agree that yu will ntify Skrill Merchant Services in advance f any changes t the infrmatin prvided herein. 6. Acknwledging and agreeing that yu have read and are bund by the terms f the Agreement (cmprising this Applicatin, the Payment Services Merchant Terms and Cnditins (including the cver pages theret), the Terms f Use, the Merchant Accunt Terms f Use and such ther dcuments as the parties may frm time t time agree, which tgether, shall cnstitute the entire Agreement between the parties) (the Agreement ). I/we cnfirm that the infrmatin prvided in the Applicatin is crrect and I/we have read and accept the Skrill Merchant Services Terms and Cnditins. Hand signed by a duly authrized representative fr and n behalf f the Merchant. Signatures PLEASE READ THE DECLARATIONS BEFORE SIGNING Signature: Print name: Psitin: Date: Signature: Print name: Psitin: Date: Skrill USA, Inc. is registered with FinCEN as a Mney Services Business (MSB) and is a licensed mney transmitter, as required by varius state laws.

Skrill Merchant Services Application Form

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