<p> PlatinumOne LLC Lease and Finance Application Information Sheet</p><p>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.</p><p>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 ______</p><p>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</p><p>Check fee schedule on “Fee Verification and Authorization” page against chart</p><p>□ 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</p>