Partner Due Diligence Form

PARTNER DUE DILIGENCE FORM (Completed by Partner, Sales)

Submitted By:

Date:
* all information kept confidential except as required by law

I. Partner Business Information

Select partner type

Bank account information - bank and account name used for program funding
(funds coming from accounts other than what is listed here will be subject to hold.)

Principal Company Officers: Name: Name: Name: Representative Contact Name: Representative Contact Title: Contact Telephone: Contact Email: Website URL(s) - Detail all web site URLs that will reference Payoneer: 1 2 3 4 5 Describe products/services offered by Partner: (Please be specific) Title: Title: Title:

Payoneer Partner Due Diligence Form, International v5 Feb. 2011

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Partner Due Diligence Form

Business Tax ID Number (US) / Business Registration number (non US): Type of Business Organization: State/Country of Incorporation/Organization: Date of Incorporation/Organization: Is the Partner a subsidiary of another company? If "Yes", name and address of parent company: Parent company name: Parent company address: Ownership of 10% or more, information for principal owners. In case that the principal is an entity, please also provide ownership information for that entity on a separate sheet, as well as the entity's Certificate of Incorporation. Ownership information is NOT required for publicly traded corporations.
# Principal Owner Name % Ownership Address

Select type

Yes

No

1 2 3 4 5 6 7 8 9 10 Documents supporting ownership. Provide one of the below detailed documents to support the ownership structure: Certified Statement showing the number of shares held by owners. Articles of partnership or Incorporation with owners names listed. Shareholders information Directors register Shareholding certificates Shareholders information submitted to a government entity such as Registrar of Companies Certified/Notarized copy of Company Annual Returns filed, showing Shareholders information. Partnership deed with owners names and shareholding defined.

Payoneer Partner Due Diligence Form, International v5 Feb. 2011

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Partner Due Diligence Form

Top 5 countries that Payees will be concentrated in: 1 2 3 4 5

II. Card Program Information

Expected Volume: Average Load Amount: Load Frequency: If Other, explain: Expected # Cards Issued Year 1: If `Second Line Embossing', wording as it will be displayed on card (25 characters is the maximum length): Daily Bi-weekly Monthly Other

Partner Payee Verification Process:

Partner Payee Terms and Conditions/Agreement of Service (please attach):

Payoneer Partner Due Diligence Form, International v5 Feb. 2011

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Partner Due Diligence Form

Guidance for Completing the PAYONEER PARTNER DUE DILIGENCE FORM Form Preparation Instructions
Partner Type: Select the type of Partner being proposed based on the type of card program, either a Payout, Travel or Stipend (clinical trial) Partner. Legal Name: Provide the official, legal name of the potential Partner, as displayed in incorporation/registration information. Doing Business As (DBA): If the Partner will be doing business with Payoneer under a name that is different from its legal name, provide the DBA name. Address: Provide the street address of the potential Partner. Additional Addresses: Provide any additional addresses used by the Partner. Principal Company Officers: Provide the names and titles of the top 3 employees of the company, such as the CEO, President, and CFO. Representative Contact Name/ Telephone/E-mail: Provide the contact information for the potential Partner employee currently managing the proposed relationship with Payoneer. Website URL(s): Provide the Internet address (URL) of the potential Partner's website, if applicable. Major business lines: Describe the main types of business that the potential Partner is engaged in, whether or not related to the proposed prepaid card program. Business Tax ID Number/Registration number: Provide the tax ID number of the potential Partner. If a potential Partner is incorporated in the US, this number will be referred to as an Employee ID Number (EIN). If a potential Partner is incorporated outside the US, this number will be the business registration number. Type of Business Organization: Select the type of company organization registered by the potential Partner, such as corporation or limited liability company. State/Country and Date of Incorporation/Organization: Provide the state and date of official registration of potential Partner. Subsidiary Identification: If the potential Partner is owned by another entity, provide name and address of parent entity. Ownership Identification: Provide the names and addresses of individuals who own 10% or more of the potential partner company, and for each, provide the amount owned in percentage. If the owner is a business entity, Payoneer will require principal owners for that company and its Certificate of Incorporation as well. Documents supporting ownership: ownership information as directed. Payoneer may request additional information as part of the verification process. Partner Payee Verification Process: Provide a description of Know Your Customer process used to verify Partner's payees. If you have a written procedure, please attach a copy. Expected Volume: Provide estimates of card program volume of the potential Partner, including expected load amounts from Partner and how often, as well as expected annual volume and expected number of cards to be issued for the first year of the proposed program. Partner Payee Verification Process: Provide details of Partner process to enroll, register and verify the identifying information of its payees/potential cardholders. Include description of identifying information collected for each individual payee as well as all methods of verifying identity of payee. Partner Payee Terms and Conditions/Agreement of Service: Provide details of terms of relationship between Partner and payee prior to proposed card program.
Payoneer Partner Due Diligence Form, International v5 Feb. 2011

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