Merchant Application

ORGANIZATION INFORMATION
Organization's Legal Name ("Applicant")

Organization's Tax ID Number

Doing Business As (DBA) Names (if applicable)

VAT ID Number

Number of Employees

Do Any Businesses Own

More Than 25% Of This
Organization? (click one)

Address - Street

YES

NO

Address - Suite

Address - City

Address State / Provence

Address Postal Code

Address - Country

Corporate Phone #

Country of Legal Entity

Legal Entity Type

Do You Have Legal Entities in

Other Countries?

YES

NO

BUSINESSINFORMATION
Brief Description of Business and Products/Services

Website(s)/URL(s) for which Transactions will be Processed

Website(s)/URL(s) for Corresponding Refund Policy

Annual Sales Volume

Average Ticket Price

Highest Ticket Price

Customer Service Phone Number

Customer Service Email Address

Partial Deposits Accepted?

(click one)

YES

NO

Third Party Fulfillment House

Used? (click one)

YES

NO

Does Business Sell Physical

Goods? (click one)

Subscriptions Offered?

YES

NO

YES

NO

YES

NO

AT SHIPMENT

OTHER

Extended Warranties Sold?

(click one)

If "YES", When is Payment

Processed? (click all that apply)

AT PURCHASE

If "AT PURCHASE " and/or "OTHER" is Clicked, Please Explain Payment and Delivery Timeframes

PROCESSING & BANKING INFORMATION

Have You Done Business With
BlueSnap Before? (click one)

Have You Ever Been On A

Chargeback Monitoring Plan?
(click one)
Name of Bank

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YES

NO

YES

NO

Have You Accepted Credit Cards

Before? (click one)

If "YES", Name of Most Recent Processor

YES

Current Chargeback %

Bank Routing Number (ABA) / BIS (SWIFT) Code

NO
Current Refund %

Bank Account Number (DDA) / IBAN Code

Merchant Application
PRINCIPAL INFO
First Name

*Primary (Owner, Partner, or Corporate Officer of merchant duly authorized to provide the information, sign this Application and bind merchant contractually)
Last Name
Ownership %

Primary Phone Number

Birth Date (enter mm/dd/yyyy)

Government Identification Number / Social Security Number (SSN#)

Home Address - Street

Home Address - City

Home Address State / Provence

Home Address - Country

PRINCIPAL INFO

Nationality

Home Address Postal Code

Email Address

Additional (Required if Principal(s) above do NOT have Ownership Stake (%) greater than 25%)

First Name

Last Name

Primary Phone Number

Ownership %

Birth Date (enter mm/dd/yyyy)

Government Identification Number / Social Security Number (SSN#)

Home Address - Street

Home Address - City

Home Address State / Provence

Home Address - Country

PRINCIPAL INFO

Home Address Postal Code

Email Address

Nationality

Additional (Required if Principal(s) above do NOT have Ownership Stake (%) greater than 25%)

First Name

Primary Phone Number

Last Name

Ownership %

Birth Date (enter mm/dd/yyyy)

Government Identification Number / Social Security Number (SSN#)

Home Address - Street

Home Address - City

Home Address - Country

Home Address State / Provence

Nationality

Home Address Postal Code

Email Address

As the person submitting this Merchant Application, I clarify that the information contained herein is true, accurate and complete. The information contained in this
document forms the basis for the relationship between Applicant and BlueSnap, Inc. Applicant understands that BlueSnap, Inc. will be relying on the information
provided to make decisions about financial services, the extension of credit and commercial inquiries. I authorize BlueSnap to verify the information furnished in this
application and receive information about Applicant and about the principal herein personally, including by requesting reports from a credit reporting agency or
background checking agency through any credit reporting agency chosen. Applicant and principal of Applicant authorize BlueSnap to obtain and use such credit reports
from time to time for the purpose of evaluating the creditworthiness of Applicant throughout the term of this Agreement. This application now belongs to BlueSnap, Inc.

Signature of Primary Principal

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Date