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Get Western Union Financial Services Pre-Qualification Form 2004-2024

WESTERN UNION FINANCIAL SERVICES 20 Corporate Hills Dr. St. Charles MO 63301 PRE-QUALIFICATION FORM FAX THIS FORM TO 800-322-0277 ATTN CREDIT DEPARTMENT WU Representative Phone Number Your Name Number of Locations COMPANY NAME Legal/dba Legal and doing business as name DESCRIPTION of BUSINESS ADDRESS CITY - STATE - ZIP FEDERAL TAX ID NUMBER PHONE NUMBER Western Union Products You are interested in Money Transfer Money Order Convenience Pay circle any products that you are interested in Do you currently offer money transfer service at any of your locations YES NO THE ABOVE-REFERENCED COMPANY THE COMPANY DESIRES TO ENTER INTO A BUSINESS RELATIONSHIP WITH WESTERN UNION FINANCIAL SERVICES INC. AND/OR INTEGRATED PAYMENT SYSTEMS INC. COLLECTIVELY WU AND HEREBY PROVIDES THE FOLLOWING INFORMATION FOR THE PURPOSE OF PRE-QUALIFYING TO OFFER ONE OR MORE OF WU S SERVICES* THE COMPANY UNDERSTANDS THAT THE ACCEPTANCE OF THIS INFORMATION BY WU DOES NOT WARRANT OR OBLIGATE WU TO ENTER INTO A BUSINESS RELATIONSHIP WITH THE COMPANY. SIGNATURE REQUIRED PRINTED NAME TITLE OWNER PRESIDENT ETC. OWNERSHIP HOME ADDRESS SOCIAL SECURITY NUMBER REQUIRED DATE Company hereby grants permission and authorization to WU and its affiliates as well as trade references Dun Bradstreet banks and consumer credit services and to state and federal governmentagencies without regard to whether they are listed herein to verify receive exchange and obtain business and/or personal credit and other information of Company or any of its principals as part of this pre-qualification process or at anytime thereafter in connection with the ongoing application evaluation process by WU. The Company further agrees that neither WU nor anyone who has furnished WU information concerning Company or its principals shall be responsible for any losses or damages resulting from said verification receipt exchange or obtaining business and/or personal credit information* PLEASE ALLOW 15 BUSINESS DAYS FOR PROCESSING Revised 08/09/04. AND/OR INTEGRATED PAYMENT SYSTEMS INC. COLLECTIVELY WU AND HEREBY PROVIDES THE FOLLOWING INFORMATION FOR THE PURPOSE OF PRE-QUALIFYING TO OFFER ONE OR MORE OF WU S SERVICES* THE COMPANY UNDERSTANDS THAT THE ACCEPTANCE OF THIS INFORMATION BY WU DOES NOT WARRANT OR OBLIGATE WU TO ENTER INTO A BUSINESS RELATIONSHIP WITH THE COMPANY. SIGNATURE REQUIRED PRINTED NAME TITLE OWNER PRESIDENT ETC. OWNERSHIP HOME ADDRESS SOCIAL SECURITY NUMBER REQUIRED DATE Company hereby grants permission and authorization to WU and its affiliates as well as trade references Dun Bradstreet banks and consumer credit services and to state and federal governmentagencies without regard to whether they are listed herein to verify receive exchange and obtain business and/or personal credit and other information of Company or any of its principals as part of this pre-qualification process or at anytime thereafter in connection with the ongoing application evaluation process by WU. SIGNATURE REQUIRED PRINTED NAME TITLE OWNER PRESIDENT ETC. OWNERSHIP HOME ADDRESS SOCIAL SECURITY NUMBER REQUIRED DATE Company hereby grants permission and authorization to WU and its affiliates as well as trade references Dun Bradstreet banks and consumer credit services and to state and federal governmentagencies without regard to whether they are listed herein to verify receive exchange and obtain business and/or personal credit and other information of Company or any of its principals as part of this pre-qualification process or at anytime thereafter in connection with the ongoing application evaluation process by WU. The Company further agrees that neither WU nor anyone who has furnished WU information concerning Company or its principals shall be responsible for any losses or damages resulting from said verification receipt exchange or obtaining business and/or personal credit information* PLEASE ALLOW 15 BUSINESS DAYS FOR PROCESSING Revised 08/09/04. .

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