PacNet Europe Questionnaire

PacNet Services (Europe) Ltd.
Account Information Questionnaire
COMPANY / ORGANIZATION DETAILS

Please provide your organizations details including correspondence address and legal registered address. Registered Company Name: Legal (Registered) Address Street: Province / County / State: Telephone: Mailing Address Street: Province / County / State: Telephone : Email: Number of Employees: Years in Business: Country / State of Incorporation: Country / State of Registration: Trading / DBA Name:
Postal Code: Fax : City: Countr y:
Postal Code: Fax: Websit e:
City: Countr y:
Main Business Activity:
Number of Directors / Partners: Date of Incorporation: Incorporation Number (if applicable): Charitable Registration Number (if applicable):
MAIN CONTACT DETAILS

Please provide details for the person or people who will be PacNets main contacts. Attach separate pages if necessary. Positio Date of 1 Name: n: Birth: . Business City: Address: Province /County Postal Countr /State: Code: y: Telepho Fax: ne: Mobile / Cell Email: Phone: 2 . Name: Positio n: Date of Birth: City: Postal Code: Fax: Countr y:
Business Address: Province /County /State: Telepho ne:
PacNet Services (Europe) Ltd., Shannon Free Zone, County Clare, Ireland Tel: +353 (0)61 714360 Fax: +353 (0)61 714369 Email: info@pacnetservices.ie

Email:
Mobile / Cell Phone: Positio n: Postal Code: Fax:
Date of Birth: City: Countr y:
3 .
Name:
Business Address: Province /County /State: Telepho ne: Email:
Mobile / Cell Phone:
DIRECTOR DETAILS
Please provide details of two company directors or principals authorised to act on behalf of the company and attach a photocopy of passport or drivers license and proof of residential address, such as a utility bill, for each. 1 . Full Name: Positio n: City: Postal Code: Office Telephone: National ity: Type: Fax: Mobile / Cell: No Number: Countr y: Date of Birth: Positio n: City: Postal Code: Office Telephone: National ity: Type: Fax: Mobile / Cell: No Number: Countr y: Date of Birth:
Residential Address: Province / County / State: Home Telephone: Email: Shareholder? Yes
National Identification Number

(Social security number or national equivalent)
2 .
Full Name:
Residential Address: Province / County / State: Home Telephone: Email: Shareholder? Yes
National Identification Number

(Social security number or national equivalent)
BENEFICIAL OWNERSHIP / SHAREHOLDER DETAILS

List company shareholder(s) with at least 10% ownership if not already listed above. 1 . Name of Shareholder: Business Address: Province/County/ State: Postal Code: Occupati on: City: Count ry: 2

2 .
3 .
4 .
Name of Shareholder: Business Address: Province/County/ State: Name of Shareholder: Business Address: Province/County/ State: Name of Shareholder: Business Address: Province/County/ State:
Postal Code: Postal Code: Postal Code:
Occupati on:
City:
Occupati on:
Count ry:
City: Occupati on: City: Count ry: Count ry:
ADDITIONAL DIRECTOR / SHAREHOLDER INFORMATION

Do any of the above named directors or shareholders or any members of their family hold one of the following positions or are they close associates or cohabitants of anyone who holds one of the following positions: a head of state or government, government minister, deputy or assistant a member of the executive council of government or member of a legislature an ambassador or an ambassadors attach or counselor a high ranking officer in the armed forces If yes, please provide name of director: a member of the administrative, management or supervisory body of a state owned enterprise a member of a court of auditors or the board of a central bank a head of a government agency a member of a supreme court, constitutional court or high-level judicial body Relationship :
Yes
No
PRODUCT / PROMOTIONAL INFORMATION

Please attach samples of all relevant mailing pieces, email solicitations or promotional materials. 1 . 2 . Description of product or service: Solicitation methods: Direct Mail Television Off the Page Advertising Internet Other: Direct Response
Outbound Telemarketing 3 . 4 . 5 . 6 . 7 . Target countries:
Payment accepted in which currency(ies)? Anticipated number of payments in each country per month: Average Individual Payment Currency: Value: Value: How long between submitting payments to PacNet and the shipping of your product?

8 .
Do you regularly have promotional material reviewed and approved by a lawyer or an advertising professional?
Yes
No
CUSTOMER SERVICE / ORDER PROCESSING / FULFILLMENT DETAILS

Please provide contact details of your customer service department or outsource customer service provider. In the unlikely event that PacNet is contacted by one of your customers, we will provide them with these details. Customer Service Company Name: Contact Name: Business Address: Province / County / State: Telephone : Email: Postal Code: Fax : Websit e: Email: City: Countr y:

Please provide contact details of your order processing / caging provider, if applicable. Order Processing Company: Contact Name: Email: Business Address: Province / County / State: Telephone : Email: Postal Code: Fax : Websit e: City: Countr y:
Please provide contact details of your fulfillment provider, if applicable. Fulfillment Company: Contact Name: Business Address: Province / County / State: Telephone : Email: Postal Code: Fax : Websit e: Email: City: Countr y:
SERVICE REQUIREMENTS
Please indicate which PacNet payment services you would like to use. PacNet will provide firm quotations of rates, set-up requirements, file format instructions, and relevant service agreements in due course. Do not hesitate to contact PacNet with questions about any of these services. PAYMENT PROCESSING Cheque Cashing Credit Collection Postal Order Cashing Direct Debit Origination Giro
ALL MARKETS:
Services available in multiplecurrencies and markets (including United States where applicable):
Visa / MasterCard Processing PAYMENT ISSUING Refund / Rebate / Winners Cheque Issuing Fulfilment Refund / Rebate / Winners Cheque
US SPECIFIC PAYMENT PROCESSING US MARKET:

Services available for USD payments originating from the United States only:
USD Electronic Debits (ACH)
USD Cheque Imaging and Conversion (ARC)
USD Cheque Imaging and Replacement (IRD) applicable for non-convertible cheque payments PAYMENT COLLECTION NSF Cheque Recovery (RCK) (*RCK automatically included with ARC Cheque Conversion - see page 6, item 9)

SERVICE / ACCOUNT MANAGEMENT INFORMATION

To ensure the efficient set-up and management of your account(s), please provide any information, contact details, bank account details, etc, we might require to carry out your instructions. Attach separate pages if necessary. 1. ACCOUNT SET-UP In which currency(ies) do you wish your PacNet account(s) to be maintained? (Please note multiple currencies require multiple accounts.) Currency(ies) of account(s): 2. TRANSACTION SUMMARY REPORTS Transaction Summary Reports are daily reports of deposits received and payments issued. TSRs can be viewed and printed through the RAVEN Online web portal. Please state the person or department responsible for retrieving transaction reports on behalf of your company. Company Name: Name of Individual or Department: Relevant Email Address: We will view Transaction Summary Reports online We require a PDF version of Transaction Summary Reports by email
We request email notification when Transaction Summary Reports are available online 3. SUBMITTER MANAGER DETAILS You may designate a person to be responsible for overseeing the submitting of Payment Files on behalf of your company. (e.g. electronic payment information: credit card charges and refunds, direct debit information, etc). Note: This person will not automatically be able to submit payments. Company Name: Name of Individual: Relevant Email Address:
4.
SUBMITTER DETAILS Please state the person or department responsible for submitting Payment Files on behalf of your company.
(e.g. electronic payment information: credit card charges and refunds, direct debit information, etc).
Company Name: Relevant Email Address: 5. PAYMENT INSTRUCTIONS
Name of Individual or Department:
Please state your preference regarding payments from your PacNet account(s): Should PacNet (a) wait for further instructions regarding disbursement of funds (b) wire funds once balance is equal to or greater than EUR 3,000.00 / GBP 3,000.00 Who is authorised to instruct PacNet to make payments from your account(s)? (please provide
identification and proof of address as requested in supporting documents).
Nam e:
Relevant Email Address:

6.
DESIGNATED BANK ACCOUNT DETAILS Please provide relevant bank account details required for forwarding of funds. Bank Name: Bank Address: Transit / Sort Code / ABA no: Account Name: Account Number: IBAN (if applicable): SWIFT Code / BIC: Currency of Account:
7. (a ) (b )
RETURNED CHEQUE / REVERSED ELECTRONIC PAYMENT INSTRUCTIONS To which e-mail address(es) should PacNet return copies of unpaid / NSF cheques? Name: Email Address: Name: Email Address: Reversed Electronic Transactions (Chargebacks) will be notified in RAVEN Online. If you are not using RAVEN Online, or prefer to receive the information by e-mail, please indicate to whom PacNet should send the notification of chargebacks. Name: Email Address: UNPROCESSABLE CHEQUES To which mailing address should PacNet return unprocessable cheques? Positio Name: n: Business City: Address: Province /County Postal Count /State: Code: ry:
8.
9. (a )
RECOVERY OF US DOLLAR NSF CHEQUES For USD cheques only: Do you wish PacNet to attempt recovery of US cheques that are returned unpaid for reason of insufficient funds (NSF)? For attempted recovery of US cheques, PacNet will charge half the percentage commission rate charged on regular cheques. YES Please attempt recovery of US cheques that are returned NSF - please go to (b) NO Do not attempt collection on US cheques that are returned NSF.

(b )
If you answered yes to (a), you must agree to print a line of advice somewhere on your advertisement or mailing piece, which says,
When you provide a check as payment, you authorise us either to use information from your check to make a one-time electronic fund transfer from your account, or to process the payment as a check transaction. When we use information from your check to make an electronic fund transfer, funds may be withdrawn from your account the same day we receive your payment; you will not receive your check back from your financial institution. In the unlikely event that your check is returned unpaid, a stateallowable handling fee may be electronically debited from your account.
Do you agree to do this and to supply PacNet with an amended mailing piece or advertisement? YES I agree to print the above advice on our US mailing pieces or advertisements, and will provide PacNet with an amended sample.
1 0.
RECOVERY OF POUND STERLING NSF CHEQUES For GBP cheques only: Do you wish PacNet to attempt recovery of GBP cheques that are returned for reason of insufficient funds (NSF)? Successfully recovered cheques will be bought into your PacNet account at a specially negotiated rate. YES I want PacNet to attempt recovery on GBP cheques that are returned NSF. Please confirm the rate. NO I do not want PacNet to attempt recovery on GBP cheques that are returned NSF.
1 1.
INDEMNITY COVERAGE FOR CHEQUE SHIPMENTS PacNet clients have access to a specially designed coverage program through AI INDEMNITY AG. For a small premium, each shipment of cheques sent to PacNet with an approved carrier will be indemnified up to a value of US $50,000.00. In the unlikely event that a package is lost or stolen on its way to PacNet, AI INDEMNITY AG, will compensate the policyholder for the value of the package less a deductible. To take advantage of this program you must apply with AI INDEMNITY AG. Do you wish to be contacted with an application and coverage details? YES I would like to receive an application and coverage details. NO I am not interested in insuring the value of cheques shipped to PacNet.
Signature:
HOW DID YOU HEAR ABOUT PACNET SERVICES?

Referred by another company: Which company? Referred by an individual: Which individual? Magazine advertisement: Which magazine? Online advertisement: Which site? Online search: Which keyword?

SUPPORTING DOCUMENTS Please attach the following documents:

Certificate of Incorporation or Business Registration Document. Copy of the articles of incorporation/bylaws, or similar for Incorporations. Copy of the articles of association or similar for entity forms other than Incorporation. Complete list of directors. Copy of the board resolution if people authorised to act on behalf of company are not present on list of directors. Notarised copy of a passport or national identity card for two company directors named in questionnaire, any person authorized by the board to sign on behalf of the company & the controlling beneficial shareholder of the company. Proof of residential address (utility bill, etc.) for two company directors & any other person authorised by the board to sign on behalf of the company. Copies of all relevant promotional materials including mailing pieces, advertisements, television spots, or other materials. Six months worth of processors statements if switching merchant service providers. Certificate of PCI Compliance See www.pcisecuritystandards.org Registration documentation for all Trading-As names, where available.
IMPORTANT NOTICE
PacNet may request additional documentation after review of this application. All copies of passports to be verified as original seen or true copy of the original by a bank manager or notary or lawyer whose name and address is to be included with the copy. PacNet must receive samples of all relevant mailing pieces or other promotional material along with completed and signed service agreements before we can set up accounts or process payments on your behalf. If service agreements have not been sent to you already, they will be issued based on information provided in this Questionnaire. As time goes on, PacNet must have opportunity to review all new mailing pieces, advertisements or promotional material before processing cheques, credit cards or other types of payment for new trading names on your behalf. Please maintain a list of active trading names and send us an update whenever there are changes.
I certify the above information to be true and correct: SIGNATURE: NAME:
DATE: day of 20
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PacNet Europe Questionnaire

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PacNet Services (Europe) Ltd.

Account Information Questionnaire

COMPANY / ORGANIZATION DETAILS

Postal Code: Fax : City: Countr y:

Postal Code: Fax: Websit e:

Main Business Activity:

MAIN CONTACT DETAILS

Business Address: Province /County /State: Telepho ne:

PacNet Services (Europe) Ltd.

Mobile / Cell Phone: Positio n: Postal Code: Fax:

Date of Birth: City: Countr y:

Business Address: Province /County /State: Telepho ne: Email:

Mobile / Cell Phone:

National Identification Number

National Identification Number

BENEFICIAL OWNERSHIP / SHAREHOLDER DETAILS

PacNet Services (Europe) Ltd.

Postal Code: Postal Code: Postal Code:

City: Occupati on: City: Count ry: Count ry:

ADDITIONAL DIRECTOR / SHAREHOLDER INFORMATION

PRODUCT / PROMOTIONAL INFORMATION

Outbound Telemarketing 3 . 4 . 5 . 6 . 7 . Target countries:

PacNet Services (Europe) Ltd.

CUSTOMER SERVICE / ORDER PROCESSING / FULFILLMENT DETAILS

PacNet Services (Europe) Ltd.

US SPECIFIC PAYMENT PROCESSING US MARKET:

USD Electronic Debits (ACH)

USD Cheque Imaging and Conversion (ARC)

PacNet Services (Europe) Ltd.

SERVICE / ACCOUNT MANAGEMENT INFORMATION

Company Name: Relevant Email Address: 5. PAYMENT INSTRUCTIONS

Name of Individual or Department:

Relevant Email Address:

PacNet Services (Europe) Ltd.

PacNet Services (Europe) Ltd.

HOW DID YOU HEAR ABOUT PACNET SERVICES?

PacNet Services (Europe) Ltd.

SUPPORTING DOCUMENTS Please attach the following documents:

I certify the above information to be true and correct: SIGNATURE: NAME:

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