Merchant Application Form for Credit and Debit Card Payment Gateway

Merchant Application Form for Credit and Debit Card Payment Gateway

MERCHANT PRE-QUAPPLICATION FORM Merchant application form With this intake form you can apply for our online payment solutions. The information provided will be used for due- diligence purposes and, if approved, will be forwarded to acquirers Legal name of company Company registration number Registered address Post code and city Country VAT number /(if applicable) Company information European Company Non-European Company (if applicable) Fax Primary contact information Merchant account information Website url(s) Business Type Year(s) in business Previous/current acquirer/processor Reason for applying a merchant account Monthly sales volume Monthly transactions number Desired processing currencies Desired settlement currencies Desired descriptor (name to appear on card statement) Desired city field (customer service phone number) Customer support e-mail Chargeback / dispute notification email IP Address(es) (servers that will connect to the gateway) Use of alternative payment methods Use of preauthorize card transactions Page 2

Website(s) information Login Details (username / password) Describe services/products sold on your website(s) Please specify the payment model (recurring, one-time payment, pay-per minute etc) What the customer will be paying for through your website When is the customer charged for purchase (upon placing an order, when shipped, upon receipt) Please specify the major countries your customers are from Do you send an email receipt to the customer? Do you have an appropriate license for your business? (Ex. Pharma, Gambling) Does your company fulfill orders directly? Do you operate any affiliate website? Please describe if you use fraud prevention techniques Please specify if you block any countries for transactions Processing History / Projected processing (if applicable) US Europe Asia Volume divided between customer in % Internet / SSL MOTO Volume divided between order type % Personal Commercial Volume divided between card types % Do you need access to a Virtual terminal (MOTO)? Projected monthly processing and number of transactions Month 1 Month 2 Month 3 Month 6 Month 9 Month 12 Page 3

Company beneficial owner(s) (Please start with the largest shareholder) Beneficial Owner # 1 Beneficial Owner # 2 Beneficial Owner # 3 First name Last name E-mail Home address City and ZIP Country Passport number % Ownership First name Last name E-mail Home address City and ZIP Country Passport number Company director(s) Director # 1 Director # 2 Director # 3 Technical Contact Information Financial Contact Information Chargeback / dispute Contact Information Page 4

Beneficiary name Account number SWIFT code IBAN Account currency Bank name Bank address Bank contact person Bank tel/fax Bank account information Page 5

Required Documents Incorporation documents: 1. Certificate of Incorporation for the Applying Company. * 2. Memorandum and Articles of Association for the Applying Company. * 3. Certificates listing the current directors, current shareholders and registered address of the Applying Company. * Personal information: 1. Passport Copies for the directors and beneficial owners and authorized signatories signing documents on behalf of the Applying Company. * 2. Original utility bill, personal bank statement or credit card statement (less than three months old), for address verification for each of the directors, beneficial owners and authorized signatories signing documents on behalf of the Applying Company.* In case of an Overlying Company(s) stated in the above mentioned corporate documents, please provide all documents listed in points 1 and 2 for it (them). * Processing statements or screenshots of current processing history showing the Applying Company s last 6 months monthly sales, chargebacks and refunds with volumes and counts included. ** 1. If there are any indications of elevated chargeback ratios, please provide an explanation as well as a chargeback reduction plan.* 2. If the applying business is a start-up and processing history is not available, please provide a detailed business plan including projected volumes, target markets and marketing strategies. * Most recent company bank statement or audited financial statements accompanied by a void check/bank letter validating the financial stability and confirming full settlement bank account details of the Applying/Overlying Company. * Declaration Letter signed by the beneficial owner of the Applying Company. * Copy of an operating license (if applicable - e.g. pharmaceutical license, gaming license, etc.)* * Original required upon approval. If original not available, certified copy of the original document authenticated by a Notary Public, Attorney, Public Accountant or Consular Official to be a true copy of the original document is required. ** Digital Scan copy or print screens are sufficient. PLEASE NOTE THAT ADDITIONAL DOCUMENTS MAY BE REQUIRED THROUGHOUT THE APPLICATION PROCESS DEPENDING ON THE PARTICULAR SOLUTION. TRANSLATION OF DOCUMENTS MAY BE REQUIRED IF LANGUAGE IS DIFFERENT FROM ENGLISH. Page 6