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MERCHANT APPLICATION FORM

Please return completely filled application form and the requested documents by email to
application@dotpay.eu

1. Company information:

CORPORATE COMPANY
Legal Company
Name:
DBA Name:
Incorporated Country:
Company URL:
Address:
Telephone:
Fax:
E-mail:
Business Entity: Public Sole Trader Gov’t Private Non Profit
Registration date:
Registration No.:

2. Company General Manager Information. List all owners greater than 10%.

DIRECTOR /CEO AUTHORIZED SHARE HOLDER/


SIGNATORY BENEFICIARY
OWNER
First Name:
Last Name:
Passport No:
Street:
City:
Country:
Title:
% of ownership:
E-mail:
Phone:
Cell:
DAY-TO-DAY CONTACT ACCOUNTING CONTACT
Name: Name:
Telephone: Telephone:
E-mail: E-mail:
TECHNICAL CONTACT RISKMANAGMENT CONTACT
Name: Name:
Telephone: Telephone:
E-mail: E-mail
COUSTOMER SERVICE CONTACT 24/7 EMERGENCY CONTACT
Name: Name:
Telephone: Telephone:
E-mail: E-mail:
Preferred Contact: Phone E-mail
Dotpay Ltd. 95 Wilton Road Suite 3, SW1V 1BZ London, UK
Customer Service: ul. Wielicka 72, 30-552 Kraków Poland, phone: +48 12 688 26 50, fax: +48 12 688 26 99, email:
office@dotpay.eu
3. Technical Specifications

TECHNICAL SPECIFICATIONS
Operating software:
Programming language:
IP – address: . . .

4. Processing Information

ESTIMATED TRANSACTION PROCESSING HISTORY


Estimated number of Have you ever YES / NO
monthly transactions: processed credit cards
before?
Total monthly sales If yes, former
volume: processor:
Average transaction Period of processing
amount: with this processor:
Min. to Max. Ticket to Reason for leaving:
amount:
Currency: USD EUR Do You use other
GBP Other payment methods?

PAYMENT & PROCESSING INFORMATION


Transaction currency: USD EUR GBP PLN Other
Settlement currency: USD EUR GBP

5. Risk Management Questionnaire

RISK MANAGEMENT PROFILE


URL Industry Product /Service

Do you have permanent customers and VIP customers? YES / NO


Can you separate new customers from permanent customers? YES / NO
Are you using a fraud prevention system e.g. card holder blocking YES /NO
process?
Are you using Preauthorization? YES /NO
Please describe the fraud prevention systems:
Do you have customer support center? YES /NO

FURTHER REQUIRED DOCUMENTS

Certificate of Incorporation (scanned and attached)

Current Utility Bill of Company (scanned and attached)

Current Utility Bill of Director (scanned and attached)

Passport Copy of Director (scanned and attached)


Dotpay Ltd. 95 Wilton Road Suite 3, SW1V 1BZ London, UK
Customer Service: ul. Wielicka 72, 30-552 Kraków Poland, phone: +48 12 688 26 50, fax: +48 12 688 26 99, email:
office@dotpay.eu
Please note: Incomplete merchant applications and missing documents will not be processed.

____________

Signature of site owner

Dotpay Ltd. 95 Wilton Road Suite 3, SW1V 1BZ London, UK


Customer Service: ul. Wielicka 72, 30-552 Kraków Poland, phone: +48 12 688 26 50, fax: +48 12 688 26 99, email:
office@dotpay.eu