New Customer Form - Aml (2)

NATIONAL GIFT CARD CORPORATION NEW CUSTOMER ACCOUNT FORM Customer

Complete!Name:

Telephone:

Address:

City:

Fax: ! Zip!Code:

Description!of!Business: Years!in!Business:

Company!Website:

DUNS!Number:

Federal!Tax!ID: !

Business! Structure

please!check!one:

Corporation:

Publicly!Owned:

Privately!Held:

Partnership:

Sole!Proprietorship:

Division!of!a!Company:

If!a!division!or!a!subsidiary!of!a!corporation:! ! Address:

Name!of!Parent: City:

Zip!Code:

! Trade References (please list 2) (please!list!

!

Name:

Telephone:

Address:

City:

Name:

Telephone:

Address:

Bank! Reference

Email!Address: Zip!Code: Code: Email!Address: City:

Bank!Name:

Contact!Person:

Bank!Address:

City:

Zip!Code:

Telephone:

State:

!

!

Company! Principals Name:

Zip!Code:

**if!privately!owned corporation/partnership, what!is!%!ownership:

**if!partnership/proprietorship, give!social!security!no:

**if!privately!owned corporation/partnership, what!is!%!ownership:

**if!partnership/proprietorship, give!social!security!no:

Position:

Home!Address:

Name:

Position:

Home!Address: ! Page!1

Program Details

Program!Description!(please!be!specific):

Estimated!Annual!Purchases!($):

DUE!DILIGENCE!PROCESS: Section!352!of!the!PATRIOT!Act!was!enacted!on!April!24,!2002!and!requires!financial!institutions!and!its!agents!to!establish!anti"money!laundering programs!as!part!of!their!Bank!Secrecy!Act!efforts.!!As!a!result,!National!Gift!Card!Corporation!NGC)!has!established!a!detailed!due!diligence process.!!As!part!of!that!due!diligence!process,!NGC!will!complete!a!detailed!background!!and!reference!check!on!the!company.!!NGC!may access!a!detailed!credit!report!and!background!checks!on!all!listed!principals. The!undersigned!acknowledges!that!I!order!to!fight!money!laundering!agrees!that!NGC!is!authorized!to!obtain!Business!Credit!Reports!and!to! undertake!a!Criminal!Background!Investigation!in!connection!with!this!Application.!!Applicant!authorizes!NGC!or!any!of!its!agents!to! investigate!information!or!data!obtained!from!this!Application.!!If!there!is!more!than!one!Principal!indicated!above,!Applicant!hereby!provides the!signed!authorization!for!such!Other!Principals!as!well.!!Applicant!agrees!to!provide!any!further!information,!including!financial!data,!as!may!be! reasonable!by!NGC.!!Applicant!may,!upon!written!request,!obtain!a!complete!and!accurate!disclosure!of!the!nature!and!scope!of!the!investigation requested!hereunder. Applicant!acknowledges!that!NGC!may!accept!or!deny!this!Application!in!its!reasonable!discretion. CONFIDENTIALITY!NOTICE:! The!data!contained!herein!is!confidential!and!proprietary!to!the!client.!!This!document!will!not!be!distributed nor!its!contents!discussed!with!parties!outside!of!National!Gift!Card!Corporation!or!its!agents!in!whole!or!in!part!without!express!written i di d ih i id f N i l Gif C d C i i i h l i ih i permission!of!the!client.

Signatures

By!signing!below,!I!certify!that!the!above!application!was!completed!to!be!best!of!my!knowledge.

Signature: Title!(Company!Officer,!Owner,!Proprietor): Date: ! Signature: !

Title!(Company!Officer,!Owner,!Proprietor): Date:

For!NGC!Use Only

Accepted!By:

Salesperson:

Acceptance!Date:

Customer!Type:

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