NATIONAL GIFT CARD CORPORATION

NEW CUSTOMER ACCOUNT FORM

Customer Complete!Name: Telephone: Fax:

!
Address: City: Zip!Code:

Description!of!Business:

Years!in!Business: Company!Website:

DUNS!Number: Federal!Tax!ID:

Business! please!check!one: Corporation: Publicly!Owned: Privately!Held:

Structure
Partnership: Sole!Proprietorship: Division!of!a!Company:

If!a!division!or!a!subsidiary!of!a!corporation:! Name!of!Parent:
!
Address: City: Zip!Code:

! !

Trade Name: Telephone: Email!Address:

References
(please list 2)
(please!list! Address: City: Zip!Code:
Code:

Name: Telephone: Email!Address:

Address: City: Zip!Code:

Bank! Bank!Name: Contact!Person: Telephone:

Reference

Bank!Address: City: State: Zip!Code:

! !

**if!privately!owned **if!partnership/proprietorship,
Company! corporation/partnership, give!social!security!no:
Principals what!is!%!ownership:
Name: Position:

Home!Address:

**if!privately!owned **if!partnership/proprietorship,
corporation/partnership, give!social!security!no:
what!is!%!ownership:

Name: Position:

Home!Address:

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

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 Accepted!By: Salesperson:

Only
Acceptance!Date: Customer!Type:

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