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ePAY(3729)
www.optimumpayments.com www.ewallet.optimumpayments.com
MerchantApplicationBusinessAnalysis
LegalBusinessName: BusinessAddress:
GeneralCompanyInformation
DBAName(DoingBusinessAs): State:
City:
Country:
Zip/PostalCode: PhoneNumber: FaxNumber: DateStarted(MM/YY): BusinessRegistration(Corp,LLC,etc.): PlaceofRegistration: TaxID/Registration#: #ofEmployees: TypeofBusiness(Retail,MLM,eComm): Products/Services: CompanyWebsite: www. CompanyeMail: ContactName: ContactNumber: AcceptCredit/DebitCards(Y/N)? IfYes CurrentService Provider: Referredby:
PrimaryOwner/Officer
(PersonwithlargestshareofOwnership)
Name Address Country Passport Name Address Country Passport# Name Address Country Passport# City Ownership% Country
nd
Title
SSN # State
DateofBirth Zip
DriversLicense# Phone #
State/Country eMailAddress
2 Owner/Officer
*
SSN# State
DateofBirth Zip
State/Country eMailAddress
FinancialOfficer*
Title City Ownership% Country DriversLicense# Phone# SSN# State DateofBirth Zip
State/Country eMailAddress
*OnlyforGlobalPaymentGateway/NetworkeSignatureAccepted1of2ConfidentialV.10.12
OptimumPaymentSolutions,Inc. 1.877.772.ePAY(3729)
www.optimumpayments.com www.ewallet.optimumpayments.com
TechnicalOfficer*
Name Address Country Passport# Title City Ownership% Country DriversLicense# Phone# SSN# State DateofBirth Zip
State/Country eMailAddress
TypeofService(s)CheckALLthatApply
TypeofService:GlobalPaymentGatewayeMerchantServicesePayrolleARNeFinancing
GlobalPaymentGateway/NetworkOnly
TypeofNetwork(1): eCommBasicStandardeGlobalBusinessExecutiveEliteMaster NetworkUsage(All):Payroll/Comm.SalesTransfersLoadCycle:InstantDailyWeeklyMonthly Countries
(ListAllonseparatesheet*)
TotalUsers
ActiveUsers
(Last60Days)
TotalTransactions
MonthlyVolume
CorporateDueDiligence(Checklist)
BankingInformation
AccountType:CheckingSavingVOIDCheckorBankletterofGoodStandingstatingaccountdetails BankName:Service/NetworkAmount:Init: NameonAccountRouting#Account#
AuthorityApplication,Banking&ComplianceAuthorization
ApplicationAuthorization:TheUndersignedrepresentsandwarrantsthathe/sheisanauthorizedrepresentativeoftheabovelistedbusinessandis authorizedtoenterintothisApplicationandAgreementonbehalfofsaidbusiness. Banking Authorization: The Undersigned declares that he/she is an authorized signer on the Account indicated above and hereby authorizes Optimum Payment Solutions (OPS) and its affiliates and subsidiaries to initiate credit and debit entries to the Account(s) indicated above on a recurringbasis.Saidcredit/debitentrieswillbeautomaticallysettledthroughtheAccount(s)indicatedaboveatthedepositorynamedabove.My authorizationtodebitmyAccountshallbethesameasifIhadpersonallysignedadrafttoOPS.IamawarethatIwillbecharged$35.00forany returneditems.Ifurtherunderstandthatmybankisnotresponsibleforanyerror(s)intheamountofanytransferredpaymentsandthattherecord ofpaymentincludedinmymonthlybankstatementshallserveasmyreceipt.Thisauthorityshallremaininfullforceandeffectduringthetermof theAgreementoruntilOPSnotifiestheUndersignedthatallmoniesduefromUndersignedunderthisAgreementhavebeenpaidinfull. PatriotAct/OFAC/KYCCompliance:BysigningbelowUndersignedindicatesalltheinformationsuppliedisaccurateandtruthfultothebestoftheir knowledge.Additionally,UndersignedauthorizesOptimumPaymentSolutionsand/ortheiraffiliatesandsubsidiariestoinvestigate/verifyanyorallof theinformationtheyveprovidedbywhatevermeansnecessaryincludingtheuseofcreditbureaus.
PrintName:Signature:Date:
*OnlyforGlobalPaymentGateway/NetworkeSignatureAccepted2of2ConfidentialV.10.12