Lease and Finance Application Information Sheet

PlatinumOne LLC Lease and Finance Application Information Sheet

The following information will be used to complete the forms required for the merchant’s program application and equipment please (if applicable), and to program the equipment specific to a merchant’s site. Once completed, the forms will be returned for review and signature.

Business name (proprietor name if proprietorship) ______D/B/A Name (if proprietorship) ______Contact Name______Title ______Mailing Address ______City ______State ______Zip ______Email address ______Business phone number ______Fax ______Type of business ______Retail Wholesale (circle one) Business start date ______Employer/Taxpayer ID Number ______Maximum check limit (circle one): $1500 $2000 $2500 $3000 $5000 Cash deal Lease deal (circle one) Estimated volume/month ______Average check ______Bank Name ______City, State ______Routing Number ______Account Number ______Owner/Partner/Officer Name ______% ownership ______O/P/O Social Security # ______Driver License ______State ______If not 51% or more owner: 2nd Owner/Partner/Officer Name ______% ownership ______2nd O/P/O Social Security # ______Driver License ______State ______Business Credit Reference 1 Business Name ______Contact Name ______Title ______Phone Number ______Business Credit Reference 2 Business Name ______Contact Name ______Title ______Phone Number ______If lease deal: Guarantor Name ______Guarantor’s Social Sec. Number ______Guarantor’s Home Address ______Guarantor’s Home City ______State ______Zip ______Phone number ______Fax ______

Telecommunications info What telecommunications options does the merchant have (phone line only, internet only, both)? ______Is the customer’s office space shared? ______Is their telecommunication line shared? ______Are they using a phone line or internet/Ethernet line for the equipment? ______If a phone line, is it analog or digital? ______If it is digital, we can provide a filter for it, but the salesperson MUST be the one to install it. If a phone line, do they need to dial 9 (or some other number) to get an outside line? ______If an internet/Ethernet line, is it a static or dynamic IP? ______Wireless is not an option at this time Underwriting Checklist

Check fee schedule on “Fee Verification and Authorization” page against chart

□ Copy of bank summary page showing beginning and ending balance □ Current state license □ IRS form with EIN □ Clear copy of driver’s license of person signing applications □ Copy of voided business check