Application for Merchant Facilities

Merchant New Accounts Level 12, 150 George Street Parramatta NSW 2150Phone: 1800 230 177

To

From

Branch number Branch/Department name Name of officer completing this application

Facsimile numberTelephone number

Section 1 – Application details

MasterCard Visa Debit

1. Nominated cards

AMEX/JCB number Diners number

2. Product

EFTPOS Mobile Leo iPod Leo iPhone UnattendedEFTPOS LiteEFTPOS Plus

Card present products

XPOS DCC MediClearIP @ POSContactless

Product options (Options not available on all products)

BPOINT CommWeb

Card not present

Please specify hardware model if required

Internet Merchant Account.

HealthPointEFTPOS Integrated (specify model) MICROS (specify model)

Barcode Reader Micros Axis GPRS

4. Merchant facilities

New merchant facility – processing method

Existing Commonwealth Bank merchant number 5 3 5 3 1 0 9

3. Terminal features

Pre-Authorisation 7 day totals Trans printMulti-Merchant PinPad lock Tipping Shift totals

Trading name

5. Business details

Registered business numberABN/ACN

Registered business name

Name(s) of registered ownersTitle Surname Full given name(s)

Driver’s Licence number OR Passport number Date of birth Email address

Driver’s Licence number OR Passport number Date of birth

Title Surname Full given name(s)

Email address

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Section 1 – Application details (continued)

Email address

Facsimile numberTelephone number Mobile number

if not trading from a fixed address

How long has the business been established? years months

6. Contact details

Position

Title Surname Full given name(s)

7. Goods and/or services

Describe the type of goods or services that your business provides

What is the maximum time between payment for and delivery of goods and services? Days

Yes NoDo you store, or intend on storing, cardholder information?

List your PCIDSS Compliant provider

Yes NoAre you compliant with the PCI DSS?

Yes NoAre all your technology and payment service providers compliant with the PCI DSS?

Address of business premises (PO Box is not acceptable)

State Postcode

Postal address (if different to above)

State Postcode

8. Are you a member or customer of any association, franchise or buying group?

Yes

Name of association, franchise or buying group Link ID

No

9. Trading Information

Estimated % of international credit cardholder transactions out of the above weekly total %

$

Debit

$

Credit

$

Debit

$

Credit

Average ticket size

How long have you held this account?

10. Banking details

Complete if separate account number is required for fees/charges

BSB Account number Full account name

BSB Account number Full account name

11. Equipment

Manual imprinter Number required Electronic terminal Number required

orPrincipal terminal user Secondary terminal userFor Multi-Merchant please specify

12. Special Facilities

MOTO Internet order Other

Do you take payment for goods and services prior to their delivery?

Yes if ‘yes’ what % of the estimated turnover does this relate to? %

No

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Section 1 – Application details (continued)

14. Receipt message

Maximum of 20 characters e.g. Thank you

13. Internet details

For businesses that operate through websites, please provide URL/domain name (must be a working website.)

Business email address

Support branch BSB number

Settlement time 9:45pm AEST Other preferred time between midnight and 9:45pm AEST

15. Settlement

Bulk credits (if more than 1 terminal) Yes NoIs everyday settlement required? Yes No

Bulk fees/charges Yes No

16. Fees

17. Special installation requirements

Refer to Fee Schedule

18. Declaration, authorisation and acknowledgement

Section 2 – What you agree to

Date website created

D D / M M / Y Y Y Y

Acknowledgment and authorisation

We collect the information in this application and other information about you to assess your application and administer your facility. ‘You’ includes any directors of the entity applying for the facility. We and other members of the Commonwealth Bank Group also use this information from time to time to tell you about products and services offered by the Group, affiliated providers and external providers for whom we act as an agent.

You must provide us with accurate and relevant information. If you do not, we may not be able to provide you with the facility you are seeking. You authorise us to undertake checks, including obtaining commercial credit reports about you from credit reporting agencies. Where not all directors are signing this application, those who are signing confirm that those who are not, are aware of this.

We may disclose your information to persons who refer you to us, other members of the Commonwealth Bank Group, and our service providers, or as permitted or required by law. For further information including how to access your information, please see our Privacy Policy Statement available at www.commbank.com.au.

If you have provided your email or mobile phone details, we may communicate with you electronically regarding your merchant facility as well as to provide you information about the Group’s products and services. If you do not wish to receive marketing information please call 1800 230 177.

Direct Debit Request (DDR) – applies where the banking account you nominate in this application (or if more than one, the one for payment of fees and charges) is not with us.

You authorise and request Commonwealth Bank – User ID 1191 (fees, chargebacks and other amounts relating to credit cards) and User ID 00952 (fees, chargebacks and other amounts relating to EFTPOS transactions) – to arrange for funds to be debited from your nominated account through the Bulk Electronic Clearing System (BECS). You authorise the Bank to verify the details of the account with your financial institution and warrant that you have account authority to sign this DDR. If you do not have account authority, please contact us and we will provide a separate form for the signatories to complete.

You acknowledge that this authority is governed by the Direct Debit Service Agreement set out below.

If eligible you may be able to accept UnionPay cards.

Declaration

•You declare that you are not an undischarged bankrupt.

•You declare that you have never had a merchant facility refused or terminated by any bank or under any card scheme.

•You acknowledge that the terms and conditions for this facility (the Merchant Agreement) will be provided at time of installation. The Merchant Agreement is also available at http://www.commbank.com.au/business/pds/customer_merchant_agreement.pdf. You should read and understand the Merchant Agreement before processing the first transaction under this facility, as it applies from that point.

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Signature Date

Position Name

✗

Signature Date

Position Name

Latest company balance sheet and profit & loss statement or completed personal balance sheet for sole proprietor or partnerships

Merchant Endorsement Form (internal use only)

A copy of either a cheque account statement, deposit slip or blank cheque

Authority for Non-Personal Accounts (A153)

Explanation/Reason for termination of merchant product from another acquirer

What we require you to send back:

Section 2 – What you agree to (continued)

Section 3 – Direct Debit Request Service Agreement – applies where your account is not with us.

Please retain this section for your records.

1 Debiting your account: By signing a DDR, you authorise us to arrange for funds to be debited from your nominated account according to the agreement we have with you and the merchant agreement referred to in the ‘declaration’ section above. We will keep your direct debit records and account details private unless this information is required by us to investigate a claim relating to an alleged incorrect or wrongful debit, or as otherwise required by law. In the event of a debit returned unpaid, we may attempt to contact you to discuss payment arrangements and/or we may attempt a redraw on your account.

2 Enquiries: If you believe there has been an error in debiting your account, you should call us on 1800 230 177 (freecall) and confirm the details in writing with us as soon as possible so that we can resolve your query quickly. If our investigations show that your account has been incorrectly debited, we will arrange for your financial institution to adjust your account accordingly. We will also notify you in writing of the amount by which your account has been adjusted. If our investigations show that your account has not been incorrectly debited, we will respond to your query by providing you with reasons and copies of any evidence for this finding. Any queries you may have about an error made in debiting your account should be directed to us in the first instance so that we can attempt to resolve the matter between you and us. If we cannot resolve the matter, you can still refer it to your financial institution.

3 Changes by us or you: We may vary any details in this agreement or a your DDR at any time by giving you at least 14 days’ written notice. You may cancel, defer and alter your authority for us to debit your account at any time by giving us 10 business days’ notice in writing before the next debit payment to be made. This notice should be given to us in the first instance. You may also stop or cancel direct debits by contacting your financial institution.

4 Your responsibility: You should:

• check with the financial institution where your account is held before signing this application form as direct debiting through the Bulk Electronic Clearing System (BECS) is not allowed on the full range of accounts. You should also complete your account details (including Bank State Branch (BSB) number) directly off a recent account statement from your financial institution. If you are in any doubt, please check with your financial institution before completing the drawing authority.

• ensure there are sufficient cleared funds available in your account to allow a debit payment to be made;

• ensure that suitable arrangements are made if the direct debit is cancelled:

– by yourself; your financial institution or for any other reason.

5. Definitions Account means the account you nominate on page 2 (or if more than one, the one for payment of fees and charges).

Banking day means a week day other than a day that’s a public holiday.

Us and We and Our means Commonwealth Bank of Australia ABN 48 123 123 124.

You means the customer(s) who signs this application form.

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