Merchant

application form

Version 01 | 01 August 2021

emerchantpay.com
Merchant Application Form
1. Applicant Company Details
Company name:
Legal name: Trading / Brand name:

Date of incorporation: Registration number:

TAX / VAT number:

Registered address:
Building name or number and street: City:

Postcode: State / province / district:

Country:

Principal place of business (if different):

City: Postcode:

State / province / district: Country:

How many individual merchant locations does your business have?

Business contact person:

Name: Title:

Phone number: E-mail address:

2. Affiliate Company Details

Company name:
Legal name: Trading / Brand name:

Date of incorporation: Registration number:

TAX / VAT number:

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 Registered address:
Building name or number and street: City:

Postcode: State / province / district:

Country:

Physical address (if different):

City: Postcode:

State / province / district: Country:

3. Payment Methods
Card payments - e-commerce:
Visa Mastercard UnionPay

Card payments - POS terminals:

Visa Mastercard UnionPay

Alternative payment methods (APMs):

4. Business Overview
Which type of business is closest to yours?
Other, which?
How long have you been in this business?

In your own words, please describe the products / services you offer, including those provided free of charge:

Please list the major countries in which you will provide products / services:

Is your product / service with physical delivery?

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4.1. How you trade
Annual business turnover: Currency:

Estimated monthly processing:

Total: Currency:

From cards: Currency:

From APMs: Currency:

Estimated number of transactions per month

Cards: APMs:

Estimated transaction value:

Minimum: Currency:

Average: Currency:

Maximum: Currency:

Percentage of sales from market:

UK: US:

EU / EEA: Rest of the world:

Percentage of payments that will be:

For product / services that will be delivered later: Deposits (upfront payments for product / service):

For memberships or subscriptions:

Which of the following risk management checks do you undertake?

BIN checks Velocity checks ✓ IP address / geo-location checks
Other:

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4.2. Card processing
Are you already taking card payments?

Name of previous processor / acquirer:

Name of current processor / acquirer:

Reason for leaving your previous acquirer(s):

How you will be taking card payments?

Face-to-face: Over the phone:
% %
E-commerce:
%
What is your average chargeback ratio for the past 6 months:
%
Visa: Mastercard:

Other card schemes:

4.3. Currencies
Processing Currency:
✓ GBP CAD ✓ EUR PLN ✓ USD Other

5. Website details
Applicant website URL (s): Status:

Non-expiring website login details for test purposes:

User ID: Password:

Descriptor:

City Field / CS phone number: Are the website domains owned by the company?

Applicant website URL (s): Status:

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 Non-expiring website login details for test purposes:
User ID: Password:

Descriptor:

City Field / CS phone number: Are the website domains owned by the company?

Applicant website URL (s): Status:

Non-expiring website login details for test purposes:

User ID: Password:

Descriptor:

City Field / CS phone number: Are the website domains owned by the company?

6. Technical information
6.1. Payment page integration
Terminal types
✓ 3D ✓ Non-3D (CVV On)
✓ Recurring ✓ MOTO
Integration request:
✓ Server to server (S2S) ✓ Virtual terminal
✓ Web payment form hosted by emerchantpay:
Web payment form hosted by 3th party:

Shopping card software:

6.2. POS terminals

How many POS terminals do you need?

Do you need to use POS terminals at multiple location? (e.g. outside your business premises)

Do you need to use POS terminals away from your till point? (e.g. at a customer`s table)

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6.3. Contact persons
Contact person (technical and PCI):

Name:

Title:

E-mail:

Phone number:

7. Settlement. Payment Account Information

Name of the Authorised Institution:

Address of the Authorised Institution:

SWIFT / routing number:

IBAN:

(Virtual) IBAN / BAN / Account number for the Merchant:

Beneficiary:

Currency:

Other details:

Contact person (accounting):

Name:

Title:

E-mail:

Phone number:

8. Management and ownership

First name:

Second name:

Last name:

Position:

Date of birth:

Passport number:

Current home address:

Building name or number and street:
City: Postcode:

State / Province / District: Country:

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E-mail address:

Phone number:

% Ownership:

First name:

Second name:

Last name:

Position:

Date of birth:

Passport number:

Current home address:

Building name or number and street:
City: Postcode:

State / Province / District: Country:

E-mail address:

Phone number:

% Ownership:

First name:

Second name:

Last name:

Position:

Date of birth:

Passport number:

Current home address:

Building name or number and street:
City: Postcode:

State / Province / District: Country:

E-mail address:

Phone number:

% Ownership:

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 First name:

Second name:

Last name:

Position:

Date of birth:

Passport number:

Current home address:

Building name or number and street:
City: Postcode:

State / Province / District: Country:

E-mail address:

Phone number:

% Ownership:

First name:

Second name:

Last name:

Position:

Date of birth:

Passport number:

Current home address:

Building name or number and street:
City: Postcode:

State / Province / District: Country:

E-mail address:

Phone number:

% Ownership:

9. Required document
a. Certificate from the Business register;
b. Articles of association;
c. Proof of identity - for directors, beneficial owners, authorised representatives (if such);

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d. Proof of address - for directors, beneficial owners, authorised representatives (if such);
e. Power of attorney - authorised representatives(if such);
f. Proof of tax / VAT registration;
g. Proof of business address - for the applying company;
h. Proof of domain ownership (if the applying company is e-commerce);
i. Shareholder structure;
j. Ownership structure;
k. Licence / authorisation - (if applicable);
l. Proof of PCI DSS compliance;
m. Payment account details;
n. Processing history statement;
o. Financial statements;
p. AML / CTF policy;
q. Completed and signed Financial Crime Prevention questionnaire.

10. Use of provided information

We will use the information provided in this Merchant Application Form in order to decide whether we can offer you the ser-
vices you apply for and to enter into Merchant Service Agreement with you.
For these purposes the information will be used by us and by our partnering acquiring banks and providers of alternative pay-
ment methods, in collaboration with which we provide you payment and ancillary services.
In addition, we can share your information with service provides we use for verification purposes, to perform identity lookups,
risk analysis, fraud prevention and risk management.
By submitting your Application you agree how your information will be used and confirm that all personal data available in
your Application is shared with us on a lawful bases (such as contract or consent).

Signature:

Name:

Title:

Date:

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Merchant application form

emerchantpay.com