AudienceView Payments Client Data Form Please complete this application form for your AudienceView Payments account. Information within this form is collected and transmitted securely. Section 1: Business Information Business Legal Name DBA Name (Alternative Business Name) Business Start Date When did your business start? Business Ownership Type Business Phone Business Fax Business Email Website State of Incorporation Federal Tax ID Number Customer Service Phone Customer Service Email Enter the email address to which customer service concerns are addressed Products Sold Section 2: Addresses Shipping / Physical Address Shipping / Physical Street Address Shipping / Physical City Shipping / Physical StatePlease select... Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia US Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territories Shipping / Physical Postal Code Shipping / Physical CountryPlease select... Canada United Kingdom United States France Germany Ireland Italy Nethelands Spain Billing Address Billing Street Address Billing City Billing StatePlease select... Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia US Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territories Billing Postal Code Billing CountryPlease select... Canada United Kingdom United States France Germany Ireland Italy Netherlands Spain Section 3: Authorized Signatory / Ownership As the authorized signatory or owner of the business, your personal information is required in order to comply with KYC guidelines as outlined in the US Per Patriot Act. This information will be used by credit reporting agencies to verify your identity. This is not a hard credit pull. First Name Last Name Title Title Type Email Address Country of Citizenship Home / Mobile Phone Birthdate Home Street Address (no PO Boxes) Home City Home StatePlease select... Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia US Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territories Home Postal Code Social Security Number Identification TypePlease select... State Issued Driver's License State Issued ID (not Driver's License) Passport ID Number No more than 15 characters, no dashes or spaces ID Issue Date ID Expiration Date ID Issuing State ID Issuing Country Ownership Percentage Must be at least 50% - does not apply to non-profits Section 4: Credit Card Processing Information This section covers your anticipated annual credit card transaction volumes. Annual Credit Card Volume $ value Highest Individual Sales Transaction / Order Value $ value Monthly Credit Card Sales Volumes $ value Average Sale Amount $ value How does your organization currently process credit card payments?(Total must add up to 100%) % Card Present % Telephone / Manually Keyed % Online / Web Sales Total must add up to 100% Section 5: Banking & Additional Attachments What is the name of your bank? What is the zip code of your local branch? Provide the following documents to your AudienceView contact. Copy of form of identification for authorized signatory listed in Section 3 Bank Letter or Voided Check (as noted below) Provide one of the following: Voided Check (cannot be a “starter check”) Bank Letter stating:Bank Letter on official Bank letterhead Date letter was written Name(s) of the Principal / Account Holder DBA or Legal Name of the business Type of account - Checking or Savings Routing number Account Number Name, Title, Signature and Contact info for the Bank Officer writing the letter Internal Fields Account Id Account Name Account Currency Form Submission ConfirmationYesNo Opportunity ID reCAPTCHA helps prevent automated form spam. The submit button will be disabled until you complete the CAPTCHA.