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MERCHANT BUSINESS VERIFICATION FORM

Please complete this form and provide documentary evidence as appropriate. Falsification,
misrepresentation of information and submission of fraudulent documentation may lead to refusal
of this application and denial of service.

INSTRUCTIONS
1) All fields marked * (asterisk) are COMPULSORY
2) All Sections should be completed in BLOCK letters/CAPITALS
3) Attach copies of relevant documents including Certificate of Companys registration or
Government Issued Identification Cards as may apply
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CONTACT INFORMATION
This section gathers information about the contact persons for your organization. VoguePay will
contact you through the information provided here.
Name of Principal Contact

Name of Secondary Contact

Position

Position

Office Telephone & Extension

Office Telephone & Extension

Mobile Phone

Mobile Phone

email Address

email Address

BUSINESS INFORMATION
Please complete this section with information about your organization.
Office Address

Business Type (please tick)


Sole Proprietorship
Partnership/Joint Venture
Limited Liability Company (LLC)

Registration Certificate No

Public Liability Company (PLC)


Non-Profit Organisation (NGO)

Principal Officers ID No

Religious Organisation
Government
Other (Please Specify)

Date Issued

Account Username (on VoguePay)

Account email Address

2014 Vogue Web Solution

WEBSITE INFORMATION
This section collects information about the products/services you intend to render on the site
Website Name

Website URL

Description of Services/Goods to be sold on site

BANK INFORMATION
Please provide details of the business primary bank account.
Bank Name

Bank Branch

Account Type (please tick)

Bank Address

Current Account
Savings Account
Other (Please Specify)
Account Name

Account Number

Country where Bank is domiciled

OTHER INFORMATION
Please provide any other relevant information here

This is a three (3) page document

2014 Vogue Web Solution

ATTESTATION

I ________________________ on behalf of ________________________ confirm that the


information provided herein are accurate and true. I also confirm that I am authorized to make this
attestation. I agree that VoguePay reserves the right to take appropriate measures including legal
actions if the information here is discovered to be false. I agree that I will provide VoguePay with
details about any transaction performed on the site upon demand.

Authorized Signature & Date __________________________ Position ________________________

This is a three (3) page document

2014 Vogue Web Solution