Questionnaire for Business Partners - Unicredit Bank

QUESTIONNAIRE FOR BUSINESS PARTNERS
Please send the questionnaire along with a copy of the current extract from the Commercial Register or trade licence not older than
3 months by post to UniCredit Bank Czech Republic, a.s., Corp. SPM/Acquiring, P.O. Box 421, 111 21 Prague 1; by fax to 221 159 112;
or via email to acquiring@unicreditgroup.cz. In case of any uncertainties, please contact your bank advisor or our product specialists at tel.
no.: 221 119 165, 221 119 157.
1. Company Information:
Company name
Company/Tax ID No. /
Registered office Street: City: Postcode:
Foreign shareholding under 50% over 50%
Majority owner/controlling entity
Web address
2. Contact Persons:
Contact for settlement: Name: Tel./mobile: Email:
Contact for technical purposes: Name: Tel./mobile: Email:
Statutory representative Name: Tel./mobile: Email:
3. Settlement and Sending Correspondence
Bank account (CZK) Account number: / Date of establishment:
Bank account in
foreign currency
EUR – account number: / IBAN:
USD – account number: / IBAN:
Method of settlement centrally at individual stores
Correspondence
address
same as company’s registered office
Street: City: Postcode:
Email for sending
electronic statements
by post (only for POS terminals)
4. Current Situation/History
We are now equipped with / we were
previously equipped with:
Electronic payment terminal (POS), through (bank name) ……
Acceptance of American Express cards
E-commerce, through (bank name)
…………
5. Internal Bank Records:
NDG: Name of bank advisor: BA’s tel. line:
UniCredit Bank Czech Republic, a.s., Registered office: Na Příkopě 858/20, 111 21 Prague 1, Commercial Register: Municipal Court in Prague, Section B, file 3608, Company ID No.: 64948242,
Bank code: 2700, www.unicreditbank.cz
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6. POS Terminal – Please only fill in the information in this box if you are interested in a POS terminal.
Store:
In case of two or more stores, please fill in a separate Questionnaire for Business Partners for each individual store or attach the following
table with the required information separately.
Name
Address Street: City: Postcode:
Authorised representative Name:
Contact information
Goods/services offered
Tel.:
Fax:
Mobile:
Email:
Business premises owned rented Date opened:
cash turnover in past calendar year
Company turnover
(CZK)
average transaction amount
new company – anticipated cash turnover per calendar month
turnover through payment cards per month:
actual anticipated
STATIONARY TERMINAL
MOBILE TERMINAL
DialUP* quantity: Bluetooth/Dial-up quantity:
TCP/IP** quantity: Bluetooth/IP quantity:
GPRS quantity: GPRS quantity:
** TCP/IP (internet line) *DialUP (analogue telephone line)
SIM card own through the service provider supplying terminal services for UCB
Foreign currency terminal EUR USD
A single terminal may accept only one currency. Having a terminal for accepting EUR and USD is conditioned upon also having a UniCredit Bank payment
terminal for accepting CZK.
Mail/telephone order:
Staff training: requested trained
requested (ability to execute transactions without the cardholder being present)
Imprinter: requested (mechanic payment card reader)
7. E-commerce – Please only fill in the information in this box if you are interested in accepting payment cards over the internet.
Name (web address)
Goods/services offered
E-shop turnover
total turnover in past calendar year
new company – expected turnover per calendar month
average purchase value
We declare that all the information provided above is true and complete. We grant express consent to UniCredit Bank Czech Republic, a.s. to
verify this information.
Name of the statutory representative:............................................................... Date of completion: ........................
Stamp, signature ……………………………………………………………………………………………………………………...
UniCredit Bank Czech Republic, a.s., Registered office: Na Příkopě 858/20, 111 21 Prague 1, Commercial Register: Municipal Court in Prague, Section B, file 3608, Company ID No.: 64948242,
Bank code: 2700, www.unicreditbank.cz
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