Official Merchant Application Form

/ Sales / Referral / Reseller ID: ______
Section A - Company Information
Merchant Registered Name
Registered Business Address
Mailing Address
Business Registration No. / SEC Reg#: / Paid Up Capital
/ USD ______
Yrs of Business:___(Yr) / Domicile Country: / Non-profit Organization
 Y  N / No. of Employees
Ownership Type /  Non-Stock/Profit  Sole Proprietor  Partnership  Corporation
Project Contact / Email
Position / Office No.
Mobile No. / Fax No.
Director Full Name
(Biggest share holder) / Surname :
Given Name(s) :
Director Identity Card No. / Passport No.
Email Address: / Contact Number/s:
Section B - Contact Information
Website URL /  Dynamic  Static  SSL? / Service Location?
Fraud Risk
Settlements
IT / 1. Contact for FRAUD here
2. Contact for Settlements here
3.Contact for IT Integrations here / Operations CSR / 1. Contact for Operations & Channel here
2. Contact for Customer Service here
Email / 1. Available Email contact here
2.
3. / Email / 1.
2.
(All a/c related issues will be sent to this email)
Tel. No. / 1. / Tel. No. / 1.
Section C - Business Information
Business Nature
Products and services / Target customer / Individual & Corporate
Current or past online payment provider / Bank /  Current : ______ Past: ______
Annual sales volume for past 2 years (USD) / Last year / Year before last year
Section D - On-line Business
Courier/delivery provider
Customer service hotline / Any returns and refunds policy? /  Yes  No
Fulfillment cycle time / ______Day / week / Receipt? /  Yes  No
Forecast Monthly Sales / After 3 months / After 6 months / After 1 year
- no. of transaction
- sales volume
Average transaction amount / USD: / USD:
Minimum transaction amount / USD: / USD:
Maximum transaction amount / USD: / USD:
Section E - Merchant Bank Details
Account Holder’s Name: / Merchant Bank’s Name:
Merchant Bank Address:
Country:
Bank Contact Information: / Main Branch
Bank Account Number/s: / ABA Routing Number:
SWIFT / IBAN Code: / Account Currency:
Intermediary Bank: / Complete Address:
Bank Account Number/s:
Bank Account Number/s: / ABA Routing Number: / SWIFT/IBAN Code:
Section F - PAYFORASIA Service Plans and Solutions
A. PAYFORASIAE-Commerce Merchant Service Plans
Card Choice / Visa ______% Transaction Ratio?
MasterCard ______% Transaction Ratio?
JCB Card ______% Transaction Ratio?
AMEX ______% Transaction Ratio?
Currency of
Transactions / Remarks:
Settlement
Currency / Remarks:
Settlement Schedule / Remarks:
Service Term /  12 Months
B. Type of Integration Set-up
Requirements
 Client Post Redirection Integration
 Direct Client Side Integration
 Direct Server Side Integration /  None
 128 bit SSL Required
 MPI Required

Application is subject to the approval by the Bank and PAYFORASIA.

Checklist for proceeding application under Corporation

PAYFORASIAOfficial Merchant Application Form Accomplished and Signed
PAYFORASIA Merchant Agreement Contract Accomplished and Signed
Payment Instruction / Authority to Debit Agreement w/ Bank Acct# Accomplished and Signed
Business Write Up Updated
Supporting Documents

a. Business Registration Certificate

b. Business Articles & by Laws

c. Business Registration (If Trade Name differs from Legal Name)

d. Bank Certificate

e. Latest Audited Financial Statement

f. Notarized Secretary Certificate

g. Travel association certificate (For Travel Agencies : ex IATA)

Checklist for proceeding application under Proprietorship

PAYFORASIA Official Merchant Application Form Accomplished and Signed
PAYFORASIA Merchant Agreement Contract Accomplished and Signed
Payment Instruction / Authority to Debit Agreement w/ Bank Acct# Accomplished and Signed
Business Write Up Updated
Supporting Documents

a. Business Registration Certificate

b. Business Registration (If Trade Name differs from Legal Name)

c. Bank Certificate (Owner’s bank account certificate)

d. Latest Audited Financial Statement

e. Travel association certificate (For Travel Agencies : ex IATA)

Merchant Online Business Declaration

Part I Merchant business nature

Agree / Disagree
A) Whenever there is any change in the business nature or goods and services sold, which is different from the information as stated on this PAYFORASIAOfficial Merchant Application Form, I will notify PAYFORASIA of the change at the earliest. / □ / □
B) I, We, participate in any of the restricted services i.e. products or services that constitute, relate to or are ancillary to, in whole or in part of:
i) Child Pornography / □ / □
ii) Child Escort services; / □ / □
iii) Goods, products, services or distributions prohibited by any applicable law or under the rules, regulations or directives of any Card Association; / □ / □

Part II Merchant website

Agree / Disagree
A)Whenever there is any change in the merchant website URL, which is different from the registered URL
as stated on this PAYFORASIAOfficial Merchant Application Form, I will notify PAYFORASIAof the change at the earliest. / □ / □
B) The PAYFORASIA account and payment service is strictly fined to the company use & do not share them
with any third party for any payment processing. / □ / □

In the event that if you are suspected and / or discovered to have violated the above conditions, an immediate action shall be taken by PAYFORASIA as follows;

a) PAYFORASIAreserves the rights to:

-Suspend or terminate your merchant account service at any time without further prior notice;

-Withhold any payment settlement for setting-off any potential fines and penalty imposed by Card Associations.

b) Subject to the violation due to Compliance concern for breach of the above clause(s) committed by your company,

-PAYFORASIA shall make you liable and or responsible for any fines and penalties imposed from Card Associations but it is subject to their charges scheme with at least a minimum amount of USD 50,000;

-Your company name and name of all directors shall also be sent to the global “Watch-out list” for monitoring by Card Associations.

Remarks:

I hereby confirm that the information provided in this PAYFORASIAOfficial Merchant Application Form is complete and accurate in all respects. I further hereby undertake and covenant with PAYFORASIA to notify you in writing forthwith of any material(s) change to that information. You are authorized to conduct a cross check to verify the information accuracy from time to time. I hereby give consent and authorize to disclose above information to any related banks, financial institutions and related companies.

FOR PAYFORASIA STAFF USE ONLY – DO NOT FILL OUT BELOW THIS LINE

□ Special Case Notice / □ No Special Case Notice
______
NAME / DESIGNATION
Checked, Completed & Endorsed by Sales:
______
NAME / DESIGNATION / Inspected and Endorsed by Verification:
______
NAME / DESIGNATION / Accomplished and Endorsed by Channel:
______
NAME / DESIGNATION
Checked, Communicated with and Endorsed by Merchant Support:
______
NAME / DESIGNATION / Accomplished and Endorsed by IT Integration:
______
NAME / DESIGNATION / Checked and Acknowledged by Settlement:
______
NAME / DESIGNATION
Assessed, Activated and Launched by:
______
PAYFORASIA

PAYFORASIA: CONFIDENTIAL FILE

Form ID: SALES TEAM Page 1 of 3Last updated: 21 June2013