Payment Facilitator Certification Intake Form

Company Legal Name (required) Please fill in your business name {{updateValidationErrorMessage('businessName1','required')}} Business name should contain at least 1 character {{updateValidationErrorMessage('businessName1','min')}} Business name should not exceed 100 characters {{updateValidationErrorMessage('businessName1','max')}} Please do not input PAN {{updateValidationErrorMessage('businessName1','noPan')}} Please enter without special characters {{updateValidationErrorMessage('businessName1','regex')}}

{{errors.first('businessName1')}}

Company DBA (required) Please fill in your Company DBA {{updateValidationErrorMessage('DBA','required')}} Company DBA should contain at least 1 character {{updateValidationErrorMessage('DBA','min')}} Company DBA should not exceed 100 characters {{updateValidationErrorMessage('DBA','max')}} Please do not input PAN {{updateValidationErrorMessage('DBA','noPan')}} Please enter without special characters {{updateValidationErrorMessage('DBA','regex')}}

{{errors.first('DBA')}}

Company Website (required) Please add company website {{updateValidationErrorMessage('websiteUrl1','required')}} Enter a valid URL address, e.g. <i>abc.com/</i> {{updateValidationErrorMessage('websiteUrl1','regex')}}

{{errors.first('websiteUrl1')}}

Business contact first name (required) Please fill in your business first name {{updateValidationErrorMessage('businessContactFirstName1','required')}} Business contact first name should contain at least 1 character {{updateValidationErrorMessage('businessContactFirstName1','min')}} Business contact first name should not exceed 100 characters {{updateValidationErrorMessage('businessContactFirstName1','max')}} Please do not input PAN {{updateValidationErrorMessage('businessContactFirstName1','noPan')}} Please enter without special characters {{updateValidationErrorMessage('businessContactFirstName1','regex')}}

{{errors.first('businessContactFirstName1')}}

Business contact last name (required) Please fill in your business last name {{updateValidationErrorMessage('businessContactLastName1','required')}} Business contact last name should contain at least 1 character {{updateValidationErrorMessage('businessContactLastName1','min')}} Business contact last name should not exceed 100 characters {{updateValidationErrorMessage('businessContactLastName1','max')}} Please do not input PAN {{updateValidationErrorMessage('businessContactLastName1','noPan')}} Please enter without special characters {{updateValidationErrorMessage('businessContactLastName1','regex')}}

{{errors.first('businessContactLastName1')}}

Email address (required) Please fill in your email address {{updateValidationErrorMessage('personalEmail1','required')}} Please limit length of email to 100 characters {{updateValidationErrorMessage('personalEmail1','max')}} Please fill in a valid email address {{updateValidationErrorMessage('personalEmail1','email')}}

{{errors.first('personalEmail1')}}

Phone Number (required)

How many total transactions do you process each year? (required)

In which countries do you operate as PF? Please list them, separated by a comma, if operating in multiple countries (required) Please add countries {{updateValidationErrorMessage('geo1','required')}} Should contain at least 1 character {{updateValidationErrorMessage('geo1','min')}} Should not exceed 100 characters {{updateValidationErrorMessage('geo1','max')}} Please do not input PAN {{updateValidationErrorMessage('geo1','noPan')}} Please enter without special characters {{updateValidationErrorMessage('geo1','regex')}}

{{errors.first('geo1')}}

If you selected Y for previous question, please provide all Visa Assigned BIDs (Comma separated)                         Should contain at least 1 character {{updateValidationErrorMessage('bids1','min')}} Should not exceed 100 characters {{updateValidationErrorMessage('bids1','max')}} Please do not input PAN {{updateValidationErrorMessage('bids1','noPan')}} Please enter without special characters {{updateValidationErrorMessage('bids1','regex')}}

{{errors.first('bids1')}}

Please identify the primary residence of the entity that will liaise with Visa and sign the agreement (required)

Provide the business email of the primary point of contact (required) Please fill in your email address {{updateValidationErrorMessage('businessEmail1','required')}} Please limit length of email to 100 characters {{updateValidationErrorMessage('businessEmail1','max')}} Please fill in a valid email address {{updateValidationErrorMessage('businessEmail1','email')}}

{{errors.first('businessEmail1')}}

{{errors.first('receiveVisaInfo1')}}