Please fill in the following form and return electronically.

Section 1: Your Company Details

Section 2: Ownership Profile (UBO’s over 25% Shareholding) Note: Please fill out separate sheet if over two persons

Section 4: Business Profile

Section 5: Current Company Bank Account

Section 6: Processing Profile

Processing History (Last Six Months)

(Please ensure that this section is filled out accurately as it will greatly assist your application)

Section 7: Sensitive Card Data Storage

Section 8: Required Documents

Please refer to separate document(s) relating to requirements

Section 9: Declarations

I hereby confirm to be the owner of the listed website(s). I further declare to have full control and authorization of the website content. I acknowledge and agree that I will not use the Processing System for transactions relating to:

. Sales made under a different trade name or business affiliation than indicated on this Agreement or otherwise approved by the acquirer in writing. 2. Fines or Penalties of any kind, losses, damages or any other costs that are beyond the Total Sale Price. 3. Any transaction that violates any law, ordinance, or regulation applicable to my business; 4. Goods which I / we know will be resold by a customer whom I / we reasonably should know is not ordinarily in the business of selling such goods. 5. Sales by third parties. 6. Any other amounts for which a customer has not specifically authorized payment through the acquirer. 7. Cash, traveller’s checks, Cash equivalents, or other negotiable instruments; or 8. Amounts which do not represent a bona fide sale of goods or services by me / us. I also declare on behalf of the company and on behalf of myself that, to the best of our knowledge, neither the company nor the website nor myself (or any of us) have ever been involved in excessive chargeback’s, fraud or content violation nor have any of the above ever terminated by an acquirer or asked by an acquirer to terminate an agreement within a set period of time

Section 10: Investigate Consumer Report

An investigative or consumer report may be made in connection with application. Merchant authorizes any party to the agreement or any of their agents to investigate the reference provided or any other statements or data obtained from merchant and from any of the undersigned personal guarantor(s), or from any person or entity with any financial obligations under this agreement. You have a right, upon written request, to a complete and accurate disclosure of the nature of and scope of the investigation requested.

Section 11: Confirmation & Applicant Signature

ePaymaker Merchant Services Privacy Statement:

ePaymaker Merchant Services hereby confirms that the information provided in this application shall not be shared and will be always handled in a confidential manner.