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 YES NO Organization? (click one)

Address - Street Address - Suite

Address - City Address – State / Provence Address – Postal Code

Address - Country Corporate Phone #

Country of Legal Entity Do You Have Legal Entities in Other Countries? YES NO

Legal Entity Type

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

Subscriptions Offered? YES NO

Third Party Fulfillment House Used? (click one) YES NO

Extended Warranties Sold? (click one) YES NO

Does Business Sell Physical Goods? (click one) YES NO

If "YES", When is Payment Processed? (click all that apply) AT PURCHASE AT SHIPMENT OTHER

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) YES NO

Have You Accepted Credit Cards Before? (click one) YES NO

If "YES", Name of Most Recent Processor

Have You Ever Been On A Chargeback Monitoring Plan? (click one)

YES NO

Current Chargeback % Current Refund %

Name of Bank Bank Routing Number (ABA) / BIS (SWIFT) Code Bank Account Number (DDA) / IBAN Code

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Merchant Application

PRINCIPAL INFO *Primary (Owner, Partner, or Corporate Officer of merchant duly authorized to provide the information, sign this Application and bind merchant contractually) First Name 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 – Postal Code

Home Address - Country Nationality Email Address

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

First Name 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 – Postal Code

Home Address - Country Nationality Email Address

PRINCIPAL INFO Additional (Required if Principal(s) above do NOT have Ownership Stake (%) greater than 25%) First Name 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 – Postal Code

Home Address - Country Nationality Email Address

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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 Date