POS REQUEST FORM Date

1. Complete every part of this form in BLOCK letters

2. Attach photocopies of relevant documents including certificate of company’s registration

COMPANY INFORMATION

Business Name

Merchant Trade Name

Type of Business: Sole Owner Partnership Limited Liability Company Public Limited Company

Others (Please specify)

SECTOR INFORMATION

Category of Merchant’s Business:

Store/Supermarket Restaurants Wholesale/Distributor Telecoms

Fuel Station Fast Food Hotel/Guest House Logistics (Courier)

Church/NGO Hospital Airlines Travel Agencies

Embassy Education/Schools Others (Please specify)

CONTACT INFORMATION

Office Address

LGA State

Name of Primary Contact Person

Designation Office Telephone

Mobile Phone Email Address

Name of Secondary Contact

Designation Office Telephone

Mobile Phone Email Address

POS OUTLET(S)

Deployment details of POS location(s) Number of POS terminal(s) required

Location of terminal Contact person Mobile phone

TRANSACTION CHARGES

Industry Local Card International Industry Local Card International

General Merchants 0.75% N/A Gaming 7.00% 10.00%

Wholesaler/Distributor 0.75% N/A Fast food/Restaurants 1.25% N/A

Fuel Station 0.00% N/A Hotel/Guest Houses 2.00 VISA/1.25% Others 5.50%
Schools/Hospital 1.25% 3.50% Others 0.75% N/A
POS NOTIFICATIONS

Daily Email notification of settlement Yes No

Email Address Mobile Number

POS Real Time transaction viewing (Monitoring Portal)

SETTLEMENT ACCOUNT DETAILS

Account name

Account Number

Branch

OTHER INFORMATION

Please provide any other relevant information in the space below:

I on behalf of ___________________________________________________________________ hereby certify that the

information provided in this form is true and accurate. I agree that ProvidusBank reserves the right to take appropriate
measure including legal actions if the information here is discovered to be false.

Local Card International MasterCard International Visa Card

Signature __________________ Designation ____________________________ Date _____________________

FOR OFFICIAL USE ONLY

To be completed by the Relationship Manager To be completed by ProvidusBank POS Officer

Merchant eligibility classification (Please tick one)
Merchant ID
Merchant Class “A” N350,000 ≥ N500,000
Merchant Class “B” N250,000 – N350,000
Merchant Class “C” N100,000 – N250,000 Terminal ID
Merchant Class “D” ≤N100,000
Relationship Manager Business Service Manager Terminal ID
Name______________________ Name______________________
Signature___________________ Signature___________________ Terminal ID
Telephone___________________ Telephone___________________
Terminal ID

Transactions to be supported on the POS terminal

Name of PTSP ___________________________

Cash Back Purchase Balance Enquiry Security/Information Zone _________________

Pin Change Transfer Mini Statement

Name and Signature _______________________
Bills Payment Cash Advance Airtime Vending

Date of Integration ________________________

Note: Your performance will be measured against your expected Monthly Transaction Value