(877) City: State: Zip: Physical Business Address: City: State: Zip:

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1 / Phone (972) / Fax (818) COMPANY INFORMATION Merchant Company Legal Name: DBA Name: Line of Business: Registered Address: (877) City: State: Zip: Physical Business Address: City: State: Zip: Size of Office Space: Number of Employees: Incorporated Country: Incorporation Date: Registration Number: Federal Tax ID (if applicable): Business Type: Corporation Partnership LLC Sole Proprietorship Other Business License Number: Authority Issuing License: Business Phone: Business Instant Messenger ID (required): COMPANY SHAREHOLDERS (with over 10% ownership) SHAREHOLDER/ BENEFICIAL OWNER SHAREHOLDER/ BENEFICIAL OWNER AUTHORIZED SIGNATORY First Name: Last Name: Percent of Ownership: Title: Address Line 1: Address Line 2: City: State (if applicable): Postal/ Zip Code (if applicable): Country: Photo ID Type and Number: Social Security Number: Phone Number: Mobile Phone Number: Personal Address: CONTACTS TECHNICAL FINANCIAL CUSTOMER SERVICE Name: Phone Number: Address: Instant Messenger ID: FORECASTED INFORMATION Average Ticket Amount: Highest Ticket Amount: Recurring: TRANSACTION DETAILS DAILY WEEKLY MONTHLY Maximum Number of Transactions : Maximum Transaction Volume: Maximum Number of Transactions Per Card: ESTIMATED MONTHLY VOLUME FOR NEXT 6 MONTHS (required) Month 1 Month 4 Month 2 Month 5 Month 3 Month 6 Last Updated June 15, 2012

2 WEBSITE INFORMATION If applying for additional websites, please attach list. List attached? Requested Descriptor: WEBSITE REQUIREMENTS Complete description of goods and services on website? Price(s) displayed? Does the sponsored merchant state that it will attend to customer service request within two working days? Company registered address clearly visible at footer of each page or in contact information on website? Customer support easily available and includes either a web contact form or an address, and a customer service phone number? Privacy policy on website? Return, refund, and cancellation policy on website? Terms of membership on website (if applicable)? Delivery policy (to include export restrictions, if any) on website? Shipping options, delivery timescales, and shipping fees present? Transaction currency(s) displayed? Display of VISA logo? Display of MasterCard logo? Site/payment page is SSL Secured? All products apply to the same MCC? Do the above URL(s) currently accept Visa/MC? Please list currency(s) offered? Describe refund policy: Describe security features and risk management measures (VbV, PCI, fraud scrubbing, etc): Are there any links on website(s) to other sites? If yes, please list link(s) and explain affiliation: WEBSITE DECLARATION I,, with an ID number of, hereby confirm to be owner and authorized signatory of (hereafter referred to as The Company ) operating website(s):. I also declare on behalf of The Company with registration number have full control and authorization of the website content., that the above named website(s) do(es) not offer any illegal content. I attest that I By signing below I acknowledge that I am responsible for the integration process of The Company website(s). I also acknowledge the list of website requirements (above) is necessary for acceptance and compliance. I acknowledge that Processor may require verification of PCI compliance at any time, and accept responsibility for maintaining all website and PCI requirements. Only transactions coming from the above mentioned website(s) will be processed through the Acquiring Gateway and no other business activity from other non-related sites will be processed through this merchant account. AUTHORIZED SIGNATORY SIGNATURE PLACE AND DATE OPERATIONS Do you have customer support? E R S 2

3 If yes, how does it work? Please provide details below: Does your company fulfill/supply orders directly? If no, please list name of supplier(s) and/or fulfillment company(s) below: Company: Address: FULFILLMENT Contact: Name: Telephone: Do you have supplier s agreement(s)? Do supplier(s) have appropriate license(s)? Is product/service fulfilled at the time of the sale? If no, please state the turnaround time from order to dispatch/ delivery time: Methods of delivery: Is insurance offered? How do you prove delivery? PAYMENT AND CURRENCY DELIVERY Please check the type(s) of payment methods requested. Visa Check21 MasterCard ACH Processing type: 3D Secure Non-3D Secure Mail Order/Telephone Order (MoTo) Internet/SSL transactions: % MOTO transactions: % USD EURO Please check the currency(s) in which your products and/or services are sold. GBP MUR Other (please specify) Other payment methods used: Are there any third party agents involved in the payment process that may have access to cardholder data? If yes, please explain. PROCESSING HISTORY Have you processed credit cards for your business in the past, or are you currently processing? How many months of processing? Processing bank s name: Reason applying for new account (if applicable)? Company total annual income (if applicable)? Current chargeback to sales ratio (if applicable)? % Have you been terminated/black listed by a processor (acquirer)? If yes, please list name of processor (acquirer) and reason. 3

4 BUSINESS OVERVIEW Describe your line of business (products/services being sold): Describe your business experience: Please detail all the membership packages and prices available: Do you offer free trial memberships? If yes, please describe free trial membership offer: Do you require registration and credit card details before the free trial membership? (if applicable) MARKETING INFORMATION Targeted markets (country/region)? Legal requirement(s), if any, for operating your business in these countries/regions: Briefly describe the marketing activities undertaken to generate sales: Are sales generated through outbound telemarketing? If yes, who performs the outbound telemarketing? COMPANY BANK DETAILS Bank Name: Account Number: Address: BUSINESS/TRADE REFERENCES (required to provide 3 references) Telephone: 4

5 CONSENT I/we are entering into a business relationship with Processor that is conditional on a satisfactory background check; I/we understand that this information is being collected for the purposes of conducting background due diligence screening and I/we declare that the information provided for this purpose is complete, true and correct, to the best of my knowledge; I/we understand that any incomplete, incorrect or false information furnished by me may disqualify me from this business proposal; I/we agree to allow a background investigation and verification of information, which will be performed by whomever Processor assigns; I hereby authorize the investigator to obtain any information concerning my employment history, education record, consumer credit record, driving record, criminal record, prohibited person information, conditional and absolute discharges that have not been removed from the national criminal records system (in accordance with the Criminal Records Act), and/or any other information in relevant to my potential business relationship with Processor; And I/we represent that no directors, shareholders, authorized signatories or other officials of the Applicant are Politically Exposed Persons (PEP) in terms of law. Processor reserves the right to request more information/documentation. The completion of this Application does not imply acceptance by Processor, which reserves the right at its absolute discretion and without incurring any liability, to decline any Application without having to give any reason for so declining. AUTHORIZED SIGNATORY SIGNATURE: PRINTED NAME: DATE: 5