Merchants Application Form - example
Merchants Details
Merchant (name) :
Contact person :
Address :
City:
Zip code
Telephone
Cell
phone:
Email
Registration / tax number:
Represented by (name of all owners /executive officers):
Shareholders (name, address) joint stock companies only
a.s.:
Type of company:
small business
Fax:
limited liability company
joint stock company
other
Established on (date). :
Are there any litigations running against your
company?
Yes
No
If so, specify details:__________________________.
Point of sales Details
Name:
Static TCP/IP address:
Contact person:
Site launched on ?
Party implementing the service
internally
externally
Name of the company:
Email:
URL
address:
Languages www site:
____________________________
____________________________
Delivery :
Prices indicated in
(currency) :
EUR
USD
Other:
Post, no registr. mail
Courier
Post , regist. mail
At the sales p.
Payment methods :
PayPal
Cash
Paymnt. cards
Other :
Other:
Delivery in foreign
country
Yes
No
Export restrictions
Yes
No
Specify if applicable:
Previous acceptant of the payment cards:
Yes
No
Specify the Bank of applicable :
Agreement terminated specify reasons :
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Business Operations
Type of business (specify goods /services):
Eur
Average monthly turnover generated by sales
point:
Payment
amount
Min.:
Eur
Eur
Eur
Average
:
Expected number of transactions (cards)
/month
Max.:
Eur
Delivery period on goods/services after the card
payment is executed :
% of services rendered 5 days after the card
payment was made to total volume of contracted
goods/ services
Thereof made with cards:
Card accepted option:
MASTERCARD
Delivery of statements:
Format:
VISA
HTML
Compression:
ZIP without password
Frequency:
Deliver to
address: :
__________
__________
XML
ZIP with
password
daily
weekly
Email 1:
Email 2:
Email 3:
Password *:
monthly
* Min. 6 characters +2 figures
Point of sale Conditions
Are the following details included in the Business Conditions/ at the Point of sale?
1. Information for customers regarding personal data protection ?
yes
no
2. Ordering procedure
yes
no
3. Option to revoke the pending order before completion
yes
no
4. Revocation mode for completed orders
yes
no
5. Returning the goods after payment
yes
no
6. Method of returning the payment after its effect (complaint , goods returned )?
yes
no
7.Overview of alternative methods of payment for goods and services
yes
no
8. Delivery methods for goods/services and delivery / dates (rendering) ?
yes
no
9. Sellers liabilities (e.g. packing, delivery of the requested goods, contracted price, invoice attached )
yes
no
10. Buyers liabilities (e.g. takeover , payment for goods ...)
yes
no
11. Discharge of buyer s liability (e.g. belated delivery of goods, damages to delivery, caused by post office, failed delivery
due to contingency events ...)?
yes
no
12. Description of complaint settlement procedure
yes
no
13. Warranty on goods and services
yes
no
14. Mode of returning the goods when the complaint is filed
yes
no
15. Comprehensive and specific description of goods and services at sales point
yes
no
16. Issuing receipt for the customer with purchase details after the order is sent/ payment executed
yes
no
17. Does Merchant have visible E-mail addresses and phone numbers for merchant customer services?
yes
no
BANK (ACQUIRER) DETAILS
Bank / financial
institution
name:
Address:
Phone number:
Account established on
(date):
Account No.:
Bank Code:
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Annexes
Please kindly attach the following documents to your request form .
Extract of register of business entities (commercial registers, trade register or other local register ) no older than 1 months
Account history for the recent 3 months (if the merchant is not client of bank, account history for the period not shorter than 12 months )
List of basic categories of goods and services at the sales point
Income tax return for the previous year
Print out of Sales points business conditions
Permit / licences for business operations issued by the local regulatory
Other documentation proposed by Bank, according to local law or Banks policy.
Statement
*I/ we hereby authorize ___________ to review information indicated herein. I /we hereby confirm, that the data referred to herein are true and
present fairly the position of merchant and have been provided in compliance with the legislation of the Republic _________. All
business activities stated herein are performed in the name of the company indicated herein, not via third party.
In
, date:
Signature:
Name:
Position:
Note: The Bank will accept only Request forms that are duly completed and presented with all attachments as required. Completed request
form, however, does not automatically constitute approval of acceptance The Bank reserves the right to request additional conditions for
purposes of card acceptance.
* The Statement shall be signed by a person / persons authorized to act on behalf of the company
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