Executed MIDsource Merchant Application (Typed Only)

6 Months Current Processing Statements

6 Months Recent Bank Statements

Corporate Documents (Articles, SS4, Business Licenses, etc.)

Corporate Tax Returns (Past 2 years)

Voided Check or Bank Letter (On Bank Letterhead: Showing full routing and account #)

Corporate Financials* (If processing over 250K Per month: P&L and Balance Sheet)

Fulfillment Agreement (If Applicable)

DL or Passport(s) For all Account Signatories /Owners

List of all URLs

Personal Utility Bill (Within 6 Months)-Must Be in the Owner's Name-Not the Corporation

CV(s) For All Account Signatories/Owners

If the business is a Startup, please include the following in place of corporate requested:

6 Months Personal Bank Statements (For Each Listed Owner)

NOTE: Based upon business type, additional requirements may be necessary. Please contact a MIDsource Representative if you should have any questions.

Phone: 1 (866) 713-MIDS (6437)Email: risk@gomidsource.comWeb: www.gomidsource.com

2 Years Personal Tax Returns (For Each Listed Owner)

Business Information: Merchant’s DBA: Merchant’s Legal Name:

Physical Address (No P.O. Box): Legal Address:

City, State, Zip: City, State, Zip:

Customer Service Phone: DBA Fax: Legal Phone: Legal Fax:

Contact Person: Contact Phone: Contact Email: URL:

Customer Service Hours: Customer Service Email:

Merchant Profile:

Federal Tax ID/ Registration#: Date & Country of Inc:

Processing Information:Ownership Type: LLC Corporation Sole Prop

Tax Exempt Partnership Other:_________ Has the business or any associated owner ever been terminated as a VISA ®/MasterCard®/Discover® Merchant? YES

NO

Describe Products or Services in Detail: YES NO

Do you currently accept VISA ®/MasterCard®/Discover®? If YES, please submit 6 current monthly statements for each merchant account currently open.

Who are you currently processing with (Please list ALL applicable ISOs and acquirers)?

How many depository bank accounts are related to these merchant accounts?

Credit Card Transaction Profile: Payment Gateway:

Sales Profile (Must equal 100%):

Card Swiped:

MOTO:

Internet:

TOTAL:

Retail

Mail / Phone

Internet

Mobile F2F Sales (Seminar)

Does the merchant accept transactions before the customer receives the product or service? Yes No

Continuity /Recurring Services? Yes NoIf YES, Please provide complete details:

If YES, does the offer have a straight sale option? (Details):

Monthly VISA / MC / Discover Sales: Average Ticket: High Ticket:

Describe high ticket in detail: Card Types Accepted: Visa MasterCard Discover

AMEX (Current SE #)_________________

Merchant Site Inspection Report:

The Merchant: Owns Leases Landlord’s Name: Merchant Location: Office Building Residence Retail Storefront

Landlord Phone: Mobile Merchant Shopping Center

Area is Zoned: Commercial Residential Industrial Square Footage: 0-250 251-500 501-2000 2001+ Does the inventory, merchandise, and staff appear to be consistent with the type of business? YES NO If no, please explain:

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Phone: 1 (866) 713-MIDS (6437) Email: risk@gomidsource.com

MIDsource Merchant Application Web: www.gomidsource.com

Credit Score / FICO:Owner 1:

Owner 2:

Credit Range:550-619

550-619

620-749

620-749

750-850

750-850

Please Estimate

Number of Employees:_______________

NMI Auth.net USAePay Other:Website Platform: Shopify Woo Big Commerce Other:

Owners / Certification of Beneficial Owner(s):

Owner 1 Name: Title: % Ownership Social Security Number:

Home Address: City: State: Zip: Own or Rent:

Time at Residence (Years): Date of Birth: Drivers License or Passport #: DL State: DL or Passport Expiration:

Home Phone: Cell Phone: Email Address: Skype ID:

Have you ever filed for Personal or Business bankruptcy?( If yes, please provide details below and submit the related discharge letter along with the application):

Owner 2 Name: Title: % Ownership Social Security Number:

Home Address: City: State: Zip: Own or Rent:

Time at Residence (Years): Date of Birth: Drivers License or Passport #: DL State: DL or Passport Expiration:

Home Phone: Cell Phone: Email Address: Skype ID:

Have you ever filed for Personal or Business bankruptcy?( If yes, please provide details below and submit the related discharge letter along with the application):

Banking Information (Please Include a Voided Check or Bank Letter):

Deposits / Withdrawals: Bank Name: Bank Account # / DDA: Routing # / ABA (9 digits): Contact Person / Bank Phone:

Deposits & Withdrawals

Deposits Only

Checking Account

Withdrawals Only

Checking Account

Cardholder Data Storage Compliance (Security):

Do you store card numbers? Yes No Are you currently PCI DSS Compliant? Yes No

Do you or your Service Provider(s) receive, pass, or transmit or store the full Cardholder Number”FCN”, electronically?

Yes No

If yes, where is card data stored? Merchant location Only

Primary Service Provider Both Merchant & Service Provider

Other:_______________________

Have you been subject to any ongoing or previous compromise investigations?

Yes No If yes, please explain:

Do you use a Fulfillment House? Yes No Phone:

Fulfillment Contact Information (Name, Contact Person, Address):

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Bank Address: Date Bank Account Opened:

Note: Federal Beneficial Owner(s) regulations require the below information for each individual who owns 25% or more of the legal entity and an individual responsible for managingthe legal entity (e.g., Chief Executive Officer, Chief Financial Officer, Managing Member, General Partner, President, Vice President, Treasurer, etc.)

Processing, Billing, Submission History, and Marketing Profile:

What is your reason for applying for a merchant account? Need Additional Volume Terminated Other

Details:_______________________________________________________________________________________________________

When is the customer charged? Time of Order Upon Shipment

How many days from the time of order does it take to deliver merchandise to the customer?

What percentage do you sell to: Business % Public %

Requested Billing Descriptor: Company Billing Contact Person (Refunds, Disputes, Chargebacks, etc.):

Name: Phone:

How do you advertise your products or services? (Catalogs, Magazines, TV, Internet, etc. List all that apply):

Please describe your warranty, return, and refund policy:

Is a Call Center used? Yes No

Call Center Name: Contact Person: Phone Number:

Call Center Address:

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What markets (Banks / ISOs) have you applied at within the past 6 months?

Do you currently have any merchant applications pending with any Bank/ISO? Yes No If YES,Please list:

Do you currently utilize any chargeback management tools? Yes No {If YES, Please provide details below}

Details:_____________________________________________________________________________________________________________

Have you ever been notified that you have been placed on the chargeback monitoring program? If so, when, why, and for how long?

Have you ever had a merchant account closed or terminated for excessive chargebacks? Yes No

If yes, please provide details {Date(s), Name of Processor(s), Name of Acquirer(s)}:

Have any of the listed owners or related entities listed herein ever been party to a lawsuit, sanction, or consumer protection inquiry by any state, federal, or regulatory agency in regards to sales and / or marketing practices? Yes No

If Yes, Please provide complete details:

To the best of your knowledge, have you ever been placed on Match? Yes No

1-7days 8-14days 14+days

FedEx UPS USPS DHL Other:

Shipping service used to deliver products?

Business Trade Supplier References:Name: Contact Person: Phone:

Name:

Product Purchased:

Product Purchased: Contact Person: Phone:

Declarations / Investigate Consumer Report:

Declarations:

I hereby confirm to be the owner of the listed website(s). I further declare to have full control and authorization of the website content. I acknowledge and agree that I will not use the Processing System for transactions relating to; 1) Sales made under a different trade name or business affiliation than indicated on this Agreement or otherwise approved by the acquirer in writing; 2) Fines or Penalties of any kind, losses, damages or any other costs that are beyond the Total Sale Price; 3) Any transaction that violates any law, ordinance, or regulation applicable to my business; 4) Goods which I / we know will be resold by a customer whom I / we reasonably should know is not ordinarily in the business of selling such goods; 5) Sales by third parties; 6) Any other amounts for which a customer has not specifically authorized payment through the acquirer; 7) Cash, traveler's checks, Cash equivalents, or other negotiable instruments; or 8) Amounts which do not represent a bona fide sale of goods or services by me /us. I also declare on behalf of the company and on behalf of myself that, to the best of our knowledge, neither the company nor the website nor myself (or any of us) have ever been involved in excessive chargeback’s, fraud or content violation nor have any of the above ever terminated by an acquirer or asked by an acquirer to terminate an agreement within a set period of time.

Further, I also understand that MIDsource can refuse to assist with and or provide processing services for my website, company, or any related or affiliated businesses I own in part or in whole at its sole discretion.

Investigate Consumer Report An investigative or consumer report may be made in connection with application. Merchant authorizes any party to the agreement or any of their agents to investigate the reference provided or any other statements or data obtained from merchant and from any of the undersigned personal guarantor(s), or from any person or entity with any financial obligations under this agreement. You have a right, upon written request, to a complete and accurate disclosure of the nature of and scope of the investigation requested.

By Signing or Printing your name below, you hereby agree and accept:

Owner #1: Date:

Owner #2: Date:

Included in the submission of:_______________________________

6 Months Processing Statements 6 Months Bank Statements Corporate Documents (Articles, SS4, Licenses, etc)

DL or Passport(s) for all account Signatories / Owners Tax Returns (Past 2 years) Voided Check or Bank Letter (CC)

Corporate Financials (P&L, Balance Sheet) Fulfillment Agreement List of all URLs

6 Months ACH Processing Statements

6 Months Personal Bank Statements (For each Listed Owner) Personal Tax Returns (Past 2 Years-For each Listed Owner)

Note: Based upon business type, additional requirements may be necessary

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If Startup, please include the following in place of Corporate Requested: