MERCHANT PROCESSING APPLICATION FORM (SPONSORED MERCHANT)

NOMINATED MERCHANT AGGREGATOR

NAME
ADDRESS

[A] SPONSORED MERCHANT DETAILS

Trading Business Name: Legal Name:

Trading Address (Primary Location) Headquarters/ Corporate Details
Street Address : Street Address:

City Landmark City Landmark

State State
Postal Code: Country: India Postal Code:
Business Phone (+ _ _ )( _ ) Contact Phone (+ _ _ )( _ )
Business Fax (+ _ _ )( _ ) Contact Fax (+ _ _ )( _ )
Contact Name: Business Registration #

Email Address _________________________ Website Address: _________________________

Date Trading Commenced: ___________________ Date Incorporated: ____/____/____ (dd/mm/yyyy)

Type of business:  Sole Trader Partnership  Limited Company Trust  Association  Other

Principal Information:
Owner/Partner/Director/Officer Details (where more than one state all, state the name of the trust and the
date of the trust deed if relevant. Note: each director to sign unless expressly agreed otherwise by us)
Title: (Circle) Mr / Mrs / Miss / Ms
First Name: __________________________________________________
Middle Name: __________________________________________________
Surname: __________________________________________________
Position: __________________________________________________
Date of Birth: ___ /____/_______ (dd/mm/yyyy)
Address __________________________________________________
City, State, Post Code________________________________________________
Phone (+ _ _ )( _ )_________________________________________
Identity / Passport Number:____________________________________________
Identification Type:  Passport  Identification Card  Other
Are you a property owner?  Yes  No
Owner/Partner/Director/Officer Details
Title: (Circle) Mr / Mrs / Miss / Ms
First Name: __________________________________________________
Middle Name: __________________________________________________
Surname: __________________________________________________
Position: __________________________________________________
Date of Birth: ___ /____/_______ (dd/mm/yyyy)
Address: __________________________________________________
City, State, Post Code________________________________________________
Phone (+ _ _ )( _ )_________________________________________
Identity / Passport Number:____________________________________________
Identification Type:  Passport  Identification Card  Other
Are you a property owner?  Yes  No
Owner/Partner/Director/Officer Details
Title: (Circle) Mr / Mrs / Miss / Ms
First Name: __________________________________________________
Middle Name: __________________________________________________
Surname: __________________________________________________
Position: __________________________________________________
Date of Birth: ___ /____/_______ (dd/mm/yyyy)
Address: __________________________________________________
City, State, Post Code________________________________________________
Phone (+ _ _ )( _ )_________________________________________
Identity / Passport Number:____________________________________________
Identification Type:  Passport  Identification Card  Other
Are you a property owner?  Yes  No

Banking information for Funding, Fees and Chargebacks:

Account Details (May be Merchant Aggregator Account except if internet aggregator):

Account Name: _____________________________

Bank Routing & Identification No. _____________ Account No. _____________
Bank Name_________________________________
Bank Address_______________________________
City ___________ _________________________
State, Post Code __________________________

Payment Advice:
Payment Advice Remittance:  Daily  Weekly  Monthly  N/A
Payment Advice Remittance: By Mail (Please select below)
 Trading Business Address
 Legal Address
 Other (please provide details below)

Street # / Name ______________________________________________

City ______________________________________________

State, ZIPCode ______________________________________________

Country India

*If you have more than one trading location, you must complete a separate Multiple Location Form, providing
address details, and bank information (if different to the Primary Location). Each location is governed by the
terms of the Transaction Documents, as defined herein after, as varied from time to time.

[B] SERVICES

1. Type of Cards
 Credit cards

 Visa  MasterCard

 Private Label Cards

Do you currently accept any of the following cards? If so, please supply your current Merchant Number.

American Express  Yes  No

SE#: ______________________

Diners Club  Yes  No

SE#: ______________________

JCB  Yes  No
SE#: ______________________

 Other Processors (I.e Debit Cards)

Name 1: _____________________ _______

SE# 1: ____________________ _______

Name 2: _____________________ _______

SE# 2: ____________________ _______

Name 3: _____________________ _______

SE# 3: ____________________ _______

2. Business Summary

Please provide a brief summary of your core service and or product:

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
______________

[ Complete the below in INR ]

Total Annual Cash/Credit/Debit Turnover: Rs____________________
Total Annual Credit (MasterCard, Visa) Turnover: Rs ____________________
Average Ticket/Sales Amount: Rs ____________________
Total Annual Private Label Turnover Rs ____________________
Total Annual Installment Loan Turnover Rs ____________________
Total Annual DCC Turnover Rs ____________________
 Total Annual Payment Gateway Turnover Rs ____________________
Average Ticket/Sales Amount : Rs ____________________
Average Ticket/Sales Amount (Installment Loans Only): Rs ____________________

Type of Transaction Volume (as a percentage of total sales INR)

 Internet ___________% Internet

 MOTO (mail or telephone order) ___________% MOTO (mail or telephone order)

 Credit Card present / face to face ___________% Credit Card present / face to face
Must equal 100%
What percentage of transactions do you process via:

Mag Swiped ___%

Chip Enabled ___%
Keyed Manually ___%

What percentage of Credit Card sales are Commercial as opposed to Consumer?

Credit Card sales to Business ___%

Credit Card sales to Consumers ___%

How long from the time of payment are the goods / services delivered / provided?

0 days ___ %-
1 - 7 days ___ %
8 – 14 days ___ %
15 – 30 days ___ %
Over 30 days ___ %

Full description of goods/services provided over 30 days

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
___________________________________________________

Are your customers required to leave a deposit?

 Yes
 No

If Yes, What percentage of transactions require a deposit: ____%

What is the minimum number of days for delivery from date of deposit? ______ days

Do any of your transactions involve automatic renewals or recurring transactions?

 Yes
 No

What is your refund policy?

 Full refund  Exchange only  No refund

If MasterCard / Visa refund, within how many days do you submit refunds?

 0-3  4-7  8-14  Over 14 days

Do you currently accept credit cards?

 Yes
 No

If yes, please provide previous processor name: _______________________________

 Previous processor merchant number: _______________________________

Do you use any third party to store, transmit or process cardholder data?

 Yes  No

If yes, please provide third party name(s):

__________________________________________________________________________

3. Processing

 Terminal Required

Terminal Type: ___________________________________

Terminal Model: ___________________________________

Number of Terminals: __________

Terminal owned ?  Yes  No

If Yes, Terminal Type: ___________________________________

 XTP Batch (Complete supplementary form)

 Installment Processing

 Online Merchant Boarding Tool (OMBT) (not applicable unless separately approved –
separate addendum needed)

 Dynamic Currency Conversion Processing (not applicable unless separately approved–

separate addendum needed)

 Internet Payment Gateway (not applicable unless separately approved – separate addendum
needed)

 PaySeal

 Other: _____________________

By signing this Merchant Processing Application Form, the Sponsored Merchant acknowledges having
received, read and understood the terms contained under the transaction documents ( the “Transaction
Documents”) , which is comprised of the Application, the Privacy Statement and Consent (which is
Schedule 1 of the attached General Terms), the General Terms and the Operating Guide and warrants
that any individual signatory is authorised to execute the Transaction Documents on behalf of the
Sponsored Merchant.

EXECUTED as a deed poll on day of 20 .

By Sponsored Merchant (please sign one of the following as appropriate)
(i) If Sponsored Merchant is a company
Executed by )
)

........................................................... ...........................................................
Company Secretary/Director Director

........................................................... ...........................................................
Name of Company Secretary/Director (print) Name of Director (print)

(ii) if Sponsored Merchant is an individual; OR

Signed sealed and delivered )
by in the presence of: )
) ...............................................................

...............................................................
Witness

...............................................................
Name of Witness (print)

(iii) if Sponsored Merchant is a partnership:

Signed by [partnership] by its duly )
authorised partner [name of partner] in the )
presence of: )

.............................................................. ..............................................................
Witness Partner

.............................................................. ..............................................................
Name of Witness (print) Name of Partner (print)

Acknowledged by Merchant Aggregator on

20

...............................................................
Authorised Representative

...............................................................
Name of Authorised Representative (print)

By individual guarantors or directors of guarantor companies

By signing this Merchant Processing Application Form, you acknowledge having received, read and
understood the Transaction Documents which is comprised of the Application, the Privacy Statement
and Consent (which is Schedule 1 of the attached General Terms), the General Terms and the Operating
Guide and consenting to the collection, use and disclosure of your personal information in accordance
with the Privacy Statement and Consent. You also agree that in consideration for ICICI Bank and ICICI
Merchant Services providing the Services to the Sponsored Merchant, you unconditionally and
irrevocably guarantee performance by the Sponsored Merchant of its obligations under the Transaction
Documents and payment of all sums due under the Transaction Documents . You understand that this is
a guarantee of payment and not of collection and that ICICI Bank and ICICI Merchant Services rely on this
guarantee for them to accept the Transaction Documents executed by the Sponsored Merchant.
 Name and Signature Date / / Name and Signature Date / /

__________________________________________

Name and Signature Date / / Name and Signature Date / /

Company Stamp Seal

By signing this Merchant Processing Application Form, the Merchant Aggregator acknowledges having
received, read and understood the terms contained under the transaction documents ( the “Transaction
Documents”) , which is comprised of the Application, the Privacy Statement and Consent (which is
Schedule 1 of the attached General Terms), the General Terms and the Operating Guide and warrants
that any individual signatory is authorised to execute the Transaction Documents on behalf of the
Merchant Aggregator.

By Merchant Aggregator (please sign one of the following as appropriate)

(i) If Merchant Aggregator is a company
Executed by )
)

........................................................... ...........................................................
Company Secretary/Director Director

........................................................... ...........................................................
Name of Company Secretary/Director (print) Name of Director (print)

(ii) if Merchant Aggregator is an individual; OR

Signed sealed and delivered )
by in the presence of: )
) ...............................................................

...............................................................
Witness

...............................................................
Name of Witness (print)

(iii) if Merchant Aggregator is a partnership:

Signed by [partnership] by its duly )
authorised partner [name of partner] in the )
presence of: )

.............................................................. ..............................................................
Witness Partner

.............................................................. ..............................................................
Name of Witness (print) Name of Partner (print)

By individual guarantors or directors of guarantor companies

By signing this Merchant Processing Application Form, you acknowledge having received, read and
understood the Transaction Documents which is comprised of the Application, the Privacy Statement
and Consent (which is Schedule 1 of the attached General Terms), the General Terms and the Operating
Guide and consenting to the collection, use and disclosure of your personal information in accordance
with the Privacy Statement and Consent. You also agree that in consideration for ICICI Bank and ICICI
Merchant Services providing the Services to the Merchant c, you unconditionally and irrevocably
guarantee performance by the Merchant Aggregator of its obligations under the Transaction Documents
and payment of all sums due under the Transaction Documents . You understand that this is a guarantee
of payment and not of collection and that ICICI Bank and ICICI Merchant Services rely on this guarantee
for them to accept the Transaction Documents executed by the Merchant Aggregator.

Name and Signature Date / / Name and Signature Date / /

__________________________________________

Name and Signature Date / / Name and Signature Date / /

Company Stamp Seal

Any queries, please contact: ICICI Merchant Services Customer Service number Phone Banking Centre,
5th floor, Mohd Illyas Khan Estate Road no:1, Banjara Hills, Hyderabad 500034