Customer Registration & Financing Application

Customer Registration & Financing Application
Program Name
Welcome to {programName} Customer Registration & Financing Application, which guides applicants through providing the information necessary to determine and approve the optimal set of financing, commerce, and payment services {programName} can provide and properly configure the {programName} Platform accordingly while complying with all applicable regulations.

By {programName} presenting this form and by Customer submitting this form, both parties agree that information exchanged shall be utilized for purposes evaluating working together.

In preparation for completing the form, below is a list of information that will need to be provided:
1. Customer information including a) legal entities b) business overview and licenses, c) address information and verification, d) management profiles, and e) relationship contacts.
2. Information and documents to verify company authorization to formalize financing, commerce and payment service relationships and signatory authorization to execute related agreements.
3. Owner information for compliance with Know Your Customer (KYC), Anti-Money Laundering (AML), and other financial regulations.
4. Banking information for authorized deposits and withdrawals.
5. Historical financial and transaction information.
6. W-9 form upload or information to complete one.

1a. Legal Entities
Legal/Registered Name
Trade Name
Business Structure
Date of Incorporation/Formation

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate the business started
Country of Incorporation/Formation
State/Province of Incorporation/Formation
State/Province Registration ID
Business License Number
Public web address of entity formation filing at governing body (e.g. Secretary Of State)
Federal Registration ID
Diversity Classification (if applicable)
D-U-N-S Number (if applicable)
SIC Code
NAICS Code
Website
Ticker(s), Exchange(s) Listed (if any)
Participating Subsidiaries and Affiliates

1b. Business Overview and Licenses
Nature of Business
What goods/services does your business provide
General commentary about the health and prospects of the business:
Market Information: Upload management information showing key market segments, geographic data and information.
Market Information

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Countries company operates in and revenues from each country
Business & Trade Licenses

1c. Address Information and Verification
Registered Legal Address

Registered Street Address

Registered Street Address Line 2

Registered CityRegistered State

Registered Zip CodeRegistered Country
Please attach proof of address for Legally Registered Address*:

*Proof of Address: Utility Bill, Bank Statement, Government Agency Record, Certified Letter from General Counsel
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Are the legal registered address, headquarters physical address, contracting office physical address, and contracting office mailing address the same?
Headquarters Physical Address

HQ Street Address

HQ Street Address Line 2

HQ CityHQ State / Province

HQ Postal / Zip CodeHQ Country
Please attach proof of address for Headquarters Physical Address*:

*Proof of Address: Utility Bill, Bank Statement, Government Agency Record, Certified Letter from General Counsel
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Are the headquarters physical address, contracting office physical address, and contracting office mailing address the same?
Contracting Office Physical Address

Physical Street Address

Physical Street Address Line 2

Physical CityPhysical State

Physical Zip CodePhysical Country
Please attach proof of address for Contracting Office Physical Address*:

*Proof of Address: Utility Bill, Bank Statement, Government Agency Record, Certified Letter from General Counsel
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Are the office physical address, and contracting office mailing address the same?
Contracting Office Mailing Address

Mailing Street Address

Mailing Street Address Line 2

Mailing CityMailing State / Province

Mailing Postal / Zip CodeMailing Country
Please attach proof of address for Contracting Office Mailing Address*:

*Proof of Address: Utility Bill, Bank Statement, Government Agency Record, Certified Letter from General Counsel
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1d. Management Profiles
Enter information for the managers of the business.
Manager Information

1e. Relationship Contacts
Enter contact information of those individuals who whill be managing the relationship with {programName}
Contact Information

2. Corporate and Signatory Authority
Corporate authority to enter into transactions involving financing, commerce, and payment services must be verified. Additionally, the legal document(s) executed with the Customer must be signed by an officer or employee of the Customer with appropriate verified signatory authority to enter into the relationship and transactions, which also must be verified.

Corporate Authority Verification:

Upload a) board resolution or b) other evidence of corporate authority (e.g. authority derived directly from constitutional documents) confirming corporate authority to enter into transactions involving financing, commerce and payment services.
Corporate Authority Verification

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Signatory Authority Verification:

Upload a) board minutes, b) Certificate of Incumbency or c) constitutional documents certifying authority of the signator(y)(ies) to legal agreement(s) for financing, commerce, and payment services.
Signatory Authority Verification

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3. Owner Information
Ownership Information for Compliance with Know Your Customer (KYC), Anti Money Laundering (AML), and other financial regulations

To fulfill all Customer related KYC / AML / other financial regulatory requirements, we need to collect information regarding Owners that have Ultimate Beneficial Ownership of 10% or more as depicted in the graphic above. Please enter details for all owners (whether individuals or entities) that have Direct or Ultimate Beneficial Ownership of 10% or greater.
Owner Information
***If there is a publicly traded company that owns 10% or greater of the business, the owners/shareholders of the publicly traded company do not need to be listed.

4. Banking Information
Authorized Withdrawals For Supplier Invoices, Periodic Billing Balances, Fee Payments and other amounts owed:
Beneficiary
Account Name
Account Type
Bank Account Number
Bank Name
IBAN Number
ABA Routing Number
BSB / Sort Code
SWIFT / BIC Code
Bank Address

Withdrawal Bank Street Address

Withdrawal Bank Street Address Line 2

Withdrawal Bank CityWithdrawal Bank State / Province

Withdrawal Bank Postal / Zip CodeWithdrawal Bank Country
Bank Verification

Upload one of the following that shows the full account number: voided check, voided deposit slip, bank statement or official bank letter
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Is the banking information for withdrawals the same as deposits?
Authorized Deposits For Settlement of Account Credits:
Beneficiary
Account Name
Account Type
Bank Account Number
Bank Name
IBAN Number
ABA Routing Number
BSB / Sort Code
SWIFT / BIC Code
Bank Address

Deposit Bank Street Address

Deposit Bank Street Address Line 2

Deposit Bank CityDeposit Bank State / Province

Deposit Bank Postal / Zip CodeDeposit Bank Country
Bank Verification

Upload one of the following that shows the full account number: voided check, voided deposit slip, bank statement or official bank letter
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5. W-9 Upload
Upload W-9 to receive funds from {programName}. If you do not have one already created, you can generate one here which is automatically submitted to {programName}
W-9 Upload

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6. Historical Financial & Transaction Information
Financials: Upload 3 years of financials and for the interim period, preferably audited, for the company as well as the highest consolidating entity in the group structure.
Financials

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Tax Statements: Upload 3 years of federal income tax statements for the company as well as the highest consolidating entity in the group structure (if not filing a consolidated return).
Tax Statements

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Accounts Payable (AP) / Accounts Receivable (AR): Upload currently open, interim period and last 3-year historical accounts payable and accounts receivable files with as many of the data elements shown in the template (downloadable here)
Account Payable (AP) / Accounts Receivable (AR)

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Forecasts and/or budgets: Upload forecasts and/or budgets for the current and future years, and order/opportunity backlog or pipeline (if available)
Forecasts and/or budgets

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Outstanding Financing Arrangements: Information of any outstanding financing guarantees or factoring arrangements currently in place:
- Any and all loan agreements and summary term sheets for all outstanding liabilities/obligations
- Schedule of all outstanding obligations due
- Planned disposition of the facility (if any) as a result of this new financing
- Termination/other fees owed to financing providers in the event of an early termination
- A detailed report of how the buyout amount has been reached to terminate an existing facility
- Details of other financing facilities (i.e. compliance certificate that provides details on any financial covenants associated with other facilities).
- Details on any liens filed by other financiers including those related to shareholder notes or equity raises to determine need of subordination and inter-creditor agreements
- Surety bonding agreements or performance guarantees
Outstanding Financing Arrangements

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Application Acknowledgement and Agreement
Applicant's Name

First NameLast Name
Applicant's Title
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Applicant's Signature
Should be Empty:

Customer Registration & Financing Application

1a. Legal Entities

1b. Business Overview and Licenses

1c. Address Information and Verification

1d. Management Profiles

1e. Relationship Contacts

2. Corporate and Signatory Authority

3. Owner Information

4. Banking Information

5. W-9 Upload

6. Historical Financial & Transaction Information

Application Acknowledgement and Agreement