Service Agreement for
SegPayUS IPSP ™
This Service Agreement for SegPayUS is made by and between Segregated Payments,
Inc, dba SegPayUS ("SegPayUS") and _________, a ______ corporation, (the "Client").
In consideration of the mutual covenants herein contained and intending to be legally
bound by the provisions of this Agreement, the parties agree as follows:
1. Retention and Engagement:
Subject to the terms and conditions set forth below, Client engages SegPayUS to provide
merchant account services and reporting through its Internet Website. Both parties to this
Service Agreement agree that the terms outlined here are reasonable and agreeable. This
entire Agreement and the stated SegPayUS' duties herein are subject to termination by
either party at any time without cause, upon ninety (90) days) days written notice, at
either parties’ sole discretion, subject to the provisions of Section 21 of this Agreement.
2. Description of Services:
SegPayUS will provide to Client and Client will purchase from SegPayUS the SegPayUS
service (the "Service"). SegPayUS service is an electronic billing and payment service
which allows Client to accept payment for their services over the Internet via one or more
of the following: via credit cards, debit cards, or online checks. As part of the Service,
SegPayUS also provides the Client with access to the SegPayUS Management System
(SMS), which allows the Client to track sales and make certain administrative changes to
its account(s) on-line.
The following terms are defined for use in this Agreement:
"Agreement" means this Service Agreement for the SegPayUS service.
"Client" means the individual or business entity that agrees to these terms and conditions
and intends to use SegPayUS service to sell access to its services. Client’s principal place
of business must be located in the United States for it to enter into this Service
"End-User" means any person desiring to purchase access to the Client's services via
"Chargeback" means an End-User charge via the SegPayUS credit card service which the
End-User's credit card issuer identifies as being invalid or non-collectible after initial
acceptance on account of fraud, lost, canceled, unissued, or invalid account identification,
an unresolved End-User complaint, or other cause which results in the deduction of the
End-User charge from monies otherwise payable to SegPayUS. "Holdback” or “Delayed
Funds” means funds withheld from client sales in order to cover Chargebacks, Returns,
Refunds, Card Association fees, indemnification obligations, or any other fees assessed.
"Proof of Purchase" means an authentication provided to End-User by SegPayUS for use
as an access device to Client's services.
"Refund" means an End-User Charge via the Service which SegPayUS, the Client, or the
End-User and SegPayUS, or the End-User and Client identify as being invalid or non-
collectible after initial acceptance on account of fraud, lost, canceled, unissued, invalid
account identification, an unresolved End-User complaint, or other cause which results in
the deduction of the End-User Charge from monies otherwise payable to SegPayUS.
“Return" means a customer charge via on-line check which the customer's bank identifies
as being invalid or non-collectible after initial acceptance on account of fraud, lost,
canceled, unissued or invalid account identification, an unresolved customer complaint,
or other cause which results in the deduction of the customer charge from monies
otherwise payable to SegPayUS.
"Service" means SegPayUS’s electronic billing and payment services and any related
products and services.
"Software" means software and related documentation provided by SegPayUS to Client
in connection with the Service.
"Total Revenue" means Client's revenues for credit card services provided before the
deduction of applicable Delayed Funds, service fees, and any other charges or
4. Fees and Delayed Funds:
4.1 Fees for SegPayUS Credit Card are equal to a percentage of Client's Total Revenues
for the SegPayUS Credit Card Service after the deduction of End-User Refunds. The
applicable service fee percentage is based on the Client's Total Revenue Commitment for
SegPayUS Credit Card and Check Services during the billing period (billing period is
based on the actual number of days in the month).
Billing Period Monthly
Commitment Volume Rate
Under $10,000K 14.50%
$10,001K- 25,000K 13.50%
$25,001K – 50,000 12.50%
$50,001 - $100,000 11.50%
Over $100,000K 10.50%
4.2 Fees for Credit Card Services Chargebacks Client shall be charged $25.00 per valid
Chargeback processed against Client's account. Fees assessed against Client hereunder, if
any, shall be applied in the month immediately following the month in which the
Chargebacks were processed.
4.3 Fees for Credit Card Services Refunds. Client shall be charged $1.00 per Refund
issued against Client's account. The Refund Fee may be increased in SegPayUS's
reasonable discretion with thirty (30) days prior written notice given to the Client.
4.4 Fees for Credit Card Services Imposed By Card Association. Client shall be
responsible for any fees imposed upon SegPayUS related to processing Client's credit
4.5 Fees for SegPayUS Online Checks. The service fee for SegPayUS Checks is 15% of
the Client's Total Revenues after the deduction of End-User Refunds.
4.6 Holdback for SegPayUS Credit Card Service and Online Check Service. SegPayUS
will withhold 5% of Client's Total Revenues for SegPayUS Credit Card and 10% for
Online Check Service for a period of six months and then release those funds in weekly
increments starting in the seventh month as Delayed Funds to cover Chargebacks and
Refunds for SegPayUS Credit Card and Online Check service. SegPayUS shall have the
right, in its sole discretion, on at least thirty (30) days written notice, to adjust the amount
held and holdback period as is deemed necessary as security against future End-User
Chargebacks, Refunds Fees, or any other obligations incurred hereunder.
4.7 Visa Annual Registration Fees. Client shall be responsible for the payment of annual
registration fees of: a) $750.00 to Visa for the first annual registration fee and $375.00 for
each subsequent annual renewal fee.
5. Payment to Client:
5.1 Payouts. Client payouts for all funds processed through Woodforest Bank are based
on activity from Tuesday through Monday. SegPayUS will process payments to Client
two weeks in arrears. The payment due the Client is equal to the sum of Client's Total
Revenues during the specified time period along with any Holdback Funds due to be
released, LESS (i) the sum of all End-User Chargebacks, and any Chargeback Fees
processed during the period, (ii) the sum of all End-User Refunds and any Refund fees
processed during the period, (iii) the applicable service fee, and (iv) all taxes, penalties,
charges and any other items reimbursable hereunder. There is no fee for direct deposits
from Woodforest and there is no minimum deposit amount.
5.2 Payments through Inteca. International Electronic Commerce Association, (“Inteca”)
is a non-profit association comprised of e-commerce companies and professional service
providers formed with the aim of promoting the industry and offering a variety of
services to merchants, organizations and other interested parties in international
electronic commerce. SegPayUS has entered into an agreement for Inteca, as an entrusted
third party payment program, to make payments to clients for a transmittal fee.
Inteca will charge $10.00 for an ACH payment and $25.00 for a wire payment against
Client's account for each transmittal. Deposits will not be made if the amount due is less
than $150.00. Any outstanding balances not credited to Client shall roll over to Client's
next billing cycle. Client authorizes Inteca to deposit amounts owed Client by initiating
credit entries to Client's financial institution indicated on the form submitted to Inteca.
Client further authorizes Client's financial institution to accept and credit any entries
indicated by Inteca to Client's account.
5.2 (a) Payment Minimum, Stop Payments. Client payments shall only be made at the
end of a payment period where the payment due to the Client is in excess of $150.00. If
the payment due to the Client at the end of a payment period is less than $150.00, then
payment to the Client shall be held over to the end of succeeding payment periods until
such time as the accumulation of Client's payments equal or exceed $150.00.
5.3 Payment to Client or Owner only. SegPayUS and Inteca will only direct payments to
the Client, the owner or parent company of the Client, or the Client's registered fictitious
or "DBA" name. Payments to affiliate partners (“Affiliates”) of Clients shall be made
only as provided under SegPayUS's Affiliate program and Section 5.5, below. Payments
will not be made to agents or representatives of Clients. SegPayUS agrees to make
payment to any third party management company authorized in writing by the Client.
5.4 Compliance with OFAC. Client shall adhere to the United States Department of the
Treasury OFAC administered sanctions in all credit card transactions
(http://www.treas.gov/offices/enforcement/ofac/sdn/). Failure to comply with this Section of
the Service Agreement shall be deemed a material breach and shall permit SegPayUS to
immediately terminate the Service Agreement, for cause.
"Spam" generally involves the sending of unsolicited commercial e-mail. The use of
Spam to promote a site receiving service hereunder is prohibited. While SegPayUS
cannot monitor the manner in which clients advertise, upon receipt of a verifiable
complaint that Spam has been generated on behalf of a site receiving Service hereunder,
SegPayUS shall provide notice to the Client. Upon the second complaint of Spam sent to
the same recipient, SegPayUS reserves the right to suspend the Client's account, until
such time as Seg Pay receives adequate assurances, within the sole discretion of
SegPayUS that the Client shall refrain from engaging in Spam.
7. End User Information:
Client understands that any information accepted by SegPayUS from End-Users is the
property of SegPayUS, and shall remain the property of SegPayUS upon termination of
this Agreement. Client shall receive from SegPayUS on a monthly basis all data that
pertains to transactional information from the End-User. The data will be delivered in a
format acceptable to the Client and that can be reasonably supplied by SegPayUS. Data
to be included are: a) Card type; b) Consumer name; c) Consumer address; d) Consumer
email; e) Username; f) Password; g) Transaction ID; h) URL; i) Purchase Status
(rebill/one time); and j) Card number: first 8 and last 4 digits.
If SegPayUS ceases processing for the Client for any reason, Client is entitled to have its
Client’s membership/client data delivered by SegPayUS in reasonable format to another
Payment Card Industry Data Security Standard (PCI) compliant processor or Merchant
Account, within 2 business days of such cessation of processing services. Full data base
details shall include the End-Users credit card number but not CVV/CVV2 information.
Storing CVV/CVV2 details are prohibited by the card associations. Client further agrees
that they shall notify the End-User in the event of a change in processor. Neither
SegPayUS nor any entity or person in any way associated with SegPayUS shall be
permitted to use, sell or give away the Client’s membership/client database or any
information from that database other than for the sole purpose of delivering the services
herein to Client.
8. Client Transaction Limits:
SegPayUS may impose limits on the amount or number of purchases which may be
charged to an individual End-User account during any time period, or refuse to accept
orders from End-Users with a prior history of questionable charges. SegPayUS may
impose transaction limits on Client either temporarily or permanently, which are more
restrictive than limits placed on other clients in order to reduce SegPayUS’s reasonable
risk of loss under varying circumstances. SegPayUS is in no way responsible for any
losses sustained by Client, including claims for lost profits, on account of the imposition
of transaction limits for any reason.
9. Refund Policy:
SegPayUS will use commercially reasonable efforts to direct inquiring and complaining
End-Users to utilize the End-User support services offered by Client in order to resolve
all disputes and complaints, however, SegPayUS reserves the right to issue a Refund
without the knowledge or consent of Client in any case that it deems appropriate.
10. Excessive End-User Inquiries, Complaints, Chargebacks, or Card Association
Client shall at all times have the ability to respond to inquiries from its End-Users
promptly and shall endeavor to resolve disputes with End-Users amicably. The
occurrence of complaints from End-Users and/or inquiries or Chargebacks regarding
Client's services may be cause for termination of this Agreement by SegPayUS if such
events occur with unacceptable frequency as determined in the sole discretion of
SegPayUS upon reasonable notice in writing. In addition, SegPayUS reserves the right to
charge Client reasonable fees and recover its expenses on account of excessive End-User
inquiries, Card Association Penalties, Refunds, or Chargebacks. Prior to imposing such
fees and attempting to recover its costs, SegPayUS shall notify Client of the details and
nature of the problems and attempt to find mutually acceptable solutions. If SegPayUS
and Client are unable to achieve mutually acceptable solutions, Client shall have the
option of continuing this Agreement subject to the additional fees and costs imposed by
SegPayUS, or of terminating this Agreement.
11. Password Security:
The security of Client's SegPayUS account is dependent in part upon the Client
maintaining the confidentiality of the SegPayUS passwords. Client is wholly responsible
for maintaining the confidentiality of Client's passwords and accounts and for any and all
activities that occur under Client's account.
12. Tangible Goods or Property:
Client may not sell tangible goods or property of any kind under this Agreement.
13. Regulation Authorization, Client Representations:
Client represents and warrants that it is legally authorized and has obtained all necessary
regulatory approvals and certificates to provide any services it intends to offer. Client
further represents and warrants that it will comply at all times with all applicable federal,
state/provincial, or local laws, rules and regulations, including any applicable card
association or Automated Clearing House rules.
Client is fully responsible for the content of its Web site and for the advertising and
promotion of all of Client's products or offerings. Client represents and warrants to
SegPayUS that it is the owner or that it has full right and authority to use and disseminate
all information, data, graphics, text, video, music or other intellectual property which
either forms a part of its Web site, which is provided by Client to End-Users, or which is
used by Client in its advertising and promotion to End-Users. The Client agrees to accept
any valid Proof of Purchase provided by SegPayUS as payment for access to the Client's
14. Client Information:
Client is responsible for providing information that is timely, complete, truthful, and not
misleading. Client will notify SegPayUS, in writing within thirty (30) days, of any
changes of ownership, regulatory actions or financial conditions that could materially
affect SegPayUS’s rights under this Agreement.
In consideration for payment of any applicable fees, Client is granted a personal, non-
exclusive, non-transferable license to use the Software, in object code form only, solely
in connection with the Service (the "License"). Client shall not: (i) attempt to reverse
engineer, decompile, disassemble or otherwise translate or modify the Software in any
manner; or (ii) sell, assign, license, sublicense or otherwise transfer, transmit or convey
Software, or any copies or modifications thereof, or any interest therein, to any third
party. Client agrees that the Software is the proprietary and confidential information of
SegPayUS and/or its licensors. The License shall immediately terminate upon the earlier
of: (i) termination or expiration of this Agreement; (ii) termination of the Service(s) with
which the Software is intended for use; or (iii) failure of Client to comply with any
provisions of this Section.
Nondisclosure of Confidential Information. Each party acknowledges that it will have
access to certain confidential information of the other party concerning the other party's
business, plans, technology, and products, and other information held in confidence by
the other party (“Confidential Information”). Confidential Information will include all
information in tangible or intangible form that is marked or designated as confidential or
that, under the circumstances of its disclosure, should be considered confidential. Each
party agrees that it will not use in any way, for its own account or the account of any third
party, except as expressly permitted by, or required to achieve the purposes of, this
Agreement, nor disclose to any third party (except as required by law or to that party’s
attorneys, accountants and other advisors as reasonably necessary), any of the other
party's Confidential Information and will take reasonable precautions to protect the
confidentiality of such information, at least as stringent as it takes to protect its own
Confidential Information. The receiving party shall be responsible for any breach of this
Section by its affiliates, agents, advisors, counsel and consultants. The obligations of this
Section shall survive the termination or expiration of this Agreement for two (2) years
Exceptions. Information will not be deemed Confidential Information hereunder if such
information: (i) is known to the receiving party prior to receipt from the disclosing party
directly or indirectly from a source other than one having an obligation of confidentiality
to the disclosing party; (ii) becomes known (independently of disclosure by the disclosing
party) to the receiving party directly or indirectly from a source other than one having an
obligation of confidentiality to the disclosing party; (iii) becomes publicly known or
otherwise ceases to be secret or confidential, except through a breach of this Agreement
by the receiving party; or (iv) is independently developed by the receiving party. The
receiving party may disclose Confidential Information pursuant to the requirements of a
governmental agency or by operation of law, provided that it gives the disclosing party
reasonable prior written notice sufficient to permit the disclosing party to contest such
The Client is fully responsible for and agrees to pay all taxes and other charges imposed
by any government authority on the services provided under this Agreement and on any
transactions processed pursuant to this Agreement. This Section shall not be construed to
impose any tax liability on the Client for any revenues or profits received by SegPayUS
or Toccata, Inc. for transactions under this Agreement.
18. Limitations of Liability:
SEGPAYUS ASSUMES NO LIABILITY FOR DISRUPTIONS OR IMPROPER
OPERATION OF THE SERVICE FOR ANY REASON, INCLUDING, BUT NOT
LIMITED TO, VANDALISM, THEFT, ACTIONS OF THIRD PARTY SERVICE
PROVIDERS, PHONE SERVICE OUTAGES, INTERNET DISRUPTIONS,
EXTREME OR SEVERE WEATHER CONDITIONS OR ANY OTHER CAUSES IN
THE NATURE OF "ACTS OF GOD" OR FORCE MAJEURE. SEGPAYUS SHALL
NOT BE RESPONSIBLE FOR ANY SPECIAL, INCIDENTAL, INDIRECT OR
CONSEQUENTIAL DAMAGES INCLUDING ANY LOSS OF PROFIT, REVENUE,
SOFTWARE OR DATA, EVEN IF SEGPAYUS IS ADVISED OF THE POSSIBLITY
OF SUCH DAMAGES. IN NO CASE SHALL CLIENT BE ENTITLED TO
RECOVER DAMAGES FROM SEGPAYUS WHICH EXCEED THE SUM OF THE
AMOUNTS OF FEES RETAINED BY SEGPAYUS UNDER THIS AGREEMENT
DURING THE ONE MONTH PRIOR TO THE EVENT GIVING RISE TO THE
CLAIM FOR DAMAGES PROVIDED THAT CLIENT SHALL ALWAYS BE
ENTITLED TO RECOVER MONIES RECEIVED BY SEGPAYUS FROM END-
USERS AND ALLEGED TO BE DUE AND OWING TO CLIENT UNDER THE
TERMS OF THIS AGREEMENT.
19. Disclaimer of Warranties:
EXCEPT AS SPECIFICALLY SET FORTH IN THIS AGREEMENT, SEGPAYUS
MAKES NO WARRANTIES, EXPRESS OR IMPLIED, AS TO ANY SEG PAY
SERVICES, RELATED PRODUCTS, SOFTWARE OR DOCUMENTATION.
SEGPAYUS SPECIFICALLY DISCLAIMS ANY AND ALL IMPLIED
WARRANTIES, INCLUDING WITHOUT LIMITATION ANY IMPLIED
WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR
Client agrees to fully defend, indemnify and hold harmless SegPayUS and its directors,
officers, employees, independent contractors and agents from and against all claims,
allegations, demands, causes of action, expenses, damages, losses, charges, liabilities,
fines, costs or penalties, including attorneys’ fees and related expenses and costs relating
to (a) the breach by Client of any representation or warranty under this Agreement; (b)
Client’s failure to perform its obligations under this Agreement; (c) fraud or
misrepresentation by Client; (d) any act or omission of Client; and (e) bodily injury to, or
death of, any person or damage to, or loss or destruction of, any property resulting from
any act or omission of Client.
SegPayUS agrees to fully defend, indemnify and hold harmless the Client and its
directors, officers, employees, independent contractors and agents from and against all
claims, allegations, demands, causes of action, expenses, damages, losses, charges,
liabilities, fines, costs or penalties, including attorneys’ fees and related expenses and
costs relating to (a) the breach by SegPayUS of any representation or warranty under this
Agreement; (b) SegPayUS’s failure to perform its obligations under this Agreement; (c)
fraud or misrepresentation by SegPayUS; (d) any act or omission of SegPayUS; and (e)
bodily injury to, or death of, any person or damage to, or loss or destruction of, any
property resulting from any act or omission of SegPayUS.
Both parties reserve the right to terminate this Agreement, without cause, upon ninety
(90) days prior written notice to the other party. Should, however, any card association or
bank provide notice to SegPayUS of its decision to stop processing transactions for any
reason, then SegPayUS shall have the right to terminate this Agreement upon thirty (30)
days written notice to Client. SegPayUS may further terminate this Agreement
immediately, without notice, at any time Client breaches any material provision of this
Agreement. Upon termination, notice of non-renewal or cancellation of this Agreement,
payment shall be made in accordance with Section 4, above.
In the event Client defaults in any provision or fails to perform pursuant to this
Agreement, SegPayUS shall be entitled to any direct damages caused by that default,
costs and attorney's fees from the Client, but shall not be responsible for any special,
incidental, indirect or consequential damages.
23. Survival of Claims:
Any claim arising out of or related to this Agreement must be pursuant to Section 26,
below, no later than one year after it has accrued.
24. Invalid or Non-enforceable Provisions:
The invalidity or non-enforceability of any provision of this Agreement, as so determined
by a court of competent jurisdiction, shall not affect the other provisions hereof, and in
any such occasion this Agreement shall be construed in all respects as if such invalid or
non-enforceable provision were omitted.
25. Account Claims and Disputes:
If another person or entity makes a claim against funds in Client's account, or if
SegPayUS has reason to believe there is or may be a dispute over matters such as
ownership of the account or the authority to receive payment or make changes to the
account, SegPayUS may, in its sole discretion, (1) continue to rely upon current
SegPayUS documents; or (2) hold the funds in an escrow account until determination of
the ownership of those funds pursuant to Section 26, below.
26. Arbitration, Venue, Choice of Law:
Except to the extent a party is entitled to injunctive or other equitable relief to enforce the
provisions of this Agreement, any controversy or claim arising out of or relating to this
Agreement or breach of this Agreement shall be settled by binding arbitration in
accordance with the Commercial Rules of the American Arbitration Association then in
effect. Any demand for arbitration by a party hereto may be served on the other party at
any time within the period provided by the applicable statute of limitations. The parties
jointly shall select one independent and impartial arbitrator. Failing agreement by the
parties, each party shall select an arbitrator who shall mutually select a third independent
and impartial arbitrator, who shall be the sole arbitrator of any such dispute. This
Agreement shall be construed and enforced in accordance with the laws of the State of
Florida and the venue for arbitration proceedings hereunder shall be Broward County,
Florida. Each party shall pay the fees of such party's own attorney, and the expenses for
such party's witnesses and all other expenses connected with presenting such party's case.
Other costs of the arbitration, including the costs of any record or transcript of the
arbitration, administrative fees, the fee of the arbitrator, and all other fees and costs, shall
be borne equally by the parties. Depositions may be taken and other discovery may be
obtained during such arbitration proceedings to the same extent as authorized in civil
judicial proceedings. The arbitrator shall not extend, modify or suspend any of the terms
of this Agreement; nor shall the arbitrator have jurisdiction to substitute the arbitrator's
judgment for that of the parties in the absence of a clear abuse of discretion established
by a preponderance of the evidence. The arbitrator shall render an award within thirty
(30) days after the close of hearing or submission of the parties' briefs, whichever is later.
The arbitrator shall not have jurisdiction to hear any controversy or claim for which a
demand for arbitration is not filed in the manner specified and within the time limits
specified herein. The arbitrator shall have no jurisdiction to award punitive or other
damages in excess of actual damage. The decision of the arbitrator within the scope of the
submission shall be final and binding on all parties, and any right to judicial action on
any matter subject to arbitration hereunder is hereby waived. Judgment upon any award
rendered by the arbitrator may be entered in any court having jurisdiction, and either
party may seek to enforce the judgment.
The captions in this Agreement are for convenience only and shall not be used in
interpreting, construing, performing or enforcing this Agreement.
28. Amendments and Modifications:
No amendment or modification of this Agreement shall be valid unless same is in writing
and signed by all parties hereto. SegPayUS may amend this Agreement to take into
account changes in law or regulations or industry mandates and to accommodate changes
imposed on SegPayUS, and to make other changes deemed necessary by SegPayUS by
sending Client a specimen of the changed Agreement, or making a specimen of the
changed Agreement available upon a web page located on the Internet. Client will be
notified of the change and location to view the change. Unless Client rejects the changed
Agreement and terminates this Agreement by notice to SegPayUS in writing within 30
days after SegPayUS sends the changed Agreement, or makes said changed Agreement
available on the Internet, the changed Agreement shall replace this Agreement and be in
full force and effect.
Any and all notices to SegPayUS, or other communications under or with respect to this
Agreement to SegPayUS, shall be in writing, and shall be delivered by hand; mailed
postage pre-paid, either by registered or certified mail, return receipt requested; or by
overnight courier to the following address, with a copy faxed to the following fax
Segregated Payments, Inc Address:
3111 North University Drive, Suite 705
Coral Springs, Florida 33065
30. Survival of Obligations:
The rights and obligations of the parties hereunder which by their nature would continue
beyond the termination or cancellation of this Agreement (including, without limitation,
those relating to confidentiality, payment of charges and limitations of liability) shall
survive any termination or cancellation of this Agreement.
31. Transfer and Assignment:
Client may not sell, assign or transfer any of its rights or obligations under this
Agreement without the prior written consent of SegPayUS.
This Agreement may be executed in counterparts, each of which shall constitute an
original and all of which shall be one and the same instrument. A facsimile copy shall
serve as an original.
33. Authorization; Entire Agreement:
The persons signing or otherwise accepting this Agreement on behalf of the Client
represent and warrant that they have the authority to enter into this Agreement on behalf
of the Client. This Agreement contains the entire agreement of the parties and supercedes
any other agreements (written or oral), instruments or writings as to its subject matter.
Segregated Payments, Inc. Client
By (Signature): By (Signature):
Print Name: ________________ Print Name: ___________________
Title: _____________________ Title: ________________________
Required Client Information (this section must be completed for account activation)
Principal Phone Number:
Principal Email Address:
Business Type: Sole Proprietor, Limited Liability Corporation, Corporation (choose one)
Business Phone Number:
Primary Identification Number #
(Passport ) : # _______________
Secondary Identification #: _______________
(Drivers License, National ID, Social Security Nr, Tax Id – choose one)
Include a copy/scan of your Passport or Drivers License (or other ID ) and Fax Page nr.
12 ONLY to efax 208-279-9519 or scan it and email to