OptimumPaymentSolutions,Inc. 1.877.772.

ePAY(3729)
www.optimumpayments.com www.ewallet.optimumpayments.com

MerchantApplicationBusinessAnalysis

LegalBusinessName: BusinessAddress:

GeneralCompanyInformation
DBAName(DoingBusinessAs): State:

City:

Country:

Zip/PostalCode: PhoneNumber: FaxNumber: DateStarted(MM/YY): BusinessRegistration(Corp,LLC,etc.): PlaceofRegistration: TaxID/Registration#: #ofEmployees: TypeofBusiness(Retail,MLM,eComm): Products/Services: CompanyWebsite: www. CompanyeMail: ContactName: ContactNumber: AcceptCredit/DebitCards(Y/N)? IfYes CurrentService Provider: Referredby:

PrimaryOwner/Officer
(PersonwithlargestshareofOwnership)

Name Address Country Passport Name Address Country Passport# Name Address Country Passport# City Ownership% Country
nd

Title

SSN # State

DateofBirth Zip

DriversLicense# Phone #

State/Country eMailAddress

2 Owner/Officer
*

Title City Ownership% Country DriversLicense# Phone#

SSN# State

DateofBirth Zip

State/Country eMailAddress

FinancialOfficer*
Title City Ownership% Country DriversLicense# Phone# SSN# State DateofBirth Zip

State/Country eMailAddress

*OnlyforGlobalPaymentGateway/NetworkeSignatureAccepted1of2ConfidentialV.10.12

OptimumPaymentSolutions,Inc. 1.877.772.ePAY(3729)
www.optimumpayments.com www.ewallet.optimumpayments.com

TechnicalOfficer*
Name Address Country Passport# Title City Ownership% Country DriversLicense# Phone# SSN# State DateofBirth Zip

State/Country eMailAddress

TypeofService(s)CheckALLthatApply
TypeofService:GlobalPaymentGatewayeMerchantServicesePayrolleARNeFinancing

GlobalPaymentGateway/NetworkOnly
TypeofNetwork(1): eCommBasicStandardeGlobalBusinessExecutiveEliteMaster NetworkUsage(All):Payroll/Comm.SalesTransfersLoadCycle:InstantDailyWeeklyMonthly Countries
(ListAllonseparatesheet*)

TotalUsers

ActiveUsers
(Last60Days)

TotalTransactions

MonthlyVolume

CorporateDueDiligence(Checklist)

PassportorDriversLicenseforallOwner(s) ArticlesofIncorporation/BusinessLicense.Mustlistownersname(s) TaxID/EINdocuments Corporatebankstatementorone(1)yearfinancialstatementormostrecenttaxreturn.

BankingInformation
AccountType:CheckingSavingVOIDCheckorBankletterofGoodStandingstatingaccountdetails BankName:Service/NetworkAmount:Init: NameonAccountRouting#Account#

AuthorityApplication,Banking&ComplianceAuthorization
ApplicationAuthorization:TheUndersignedrepresentsandwarrantsthathe/sheisanauthorizedrepresentativeoftheabovelistedbusinessandis authorizedtoenterintothisApplicationandAgreementonbehalfofsaidbusiness. Banking Authorization: The Undersigned declares that he/she is an authorized signer on the Account indicated above and hereby authorizes Optimum Payment Solutions (OPS) and its affiliates and subsidiaries to initiate credit and debit entries to the Account(s) indicated above on a recurringbasis.Saidcredit/debitentrieswillbeautomaticallysettledthroughtheAccount(s)indicatedaboveatthedepositorynamedabove.My authorizationtodebitmyAccountshallbethesameasifIhadpersonallysignedadrafttoOPS.IamawarethatIwillbecharged$35.00forany returneditems.Ifurtherunderstandthatmybankisnotresponsibleforanyerror(s)intheamountofanytransferredpaymentsandthattherecord ofpaymentincludedinmymonthlybankstatementshallserveasmyreceipt.Thisauthorityshallremaininfullforceandeffectduringthetermof theAgreementoruntilOPSnotifiestheUndersignedthatallmoniesduefromUndersignedunderthisAgreementhavebeenpaidinfull. PatriotAct/OFAC/KYCCompliance:BysigningbelowUndersignedindicatesalltheinformationsuppliedisaccurateandtruthfultothebestoftheir knowledge.Additionally,UndersignedauthorizesOptimumPaymentSolutionsand/ortheiraffiliatesandsubsidiariestoinvestigate/verifyanyorallof theinformationtheyveprovidedbywhatevermeansnecessaryincludingtheuseofcreditbureaus.

PrintName:Signature:Date:

*OnlyforGlobalPaymentGateway/NetworkeSignatureAccepted2of2ConfidentialV.10.12