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Republic Online Banking
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Customer Information
Are you an existing Republic Bank customer?
Yes
No
If yes, are you an existing Merchant Services customer?
Yes
No
Registered Name of Business
Year Established
DBA Name (If Different From Above)
Principals (Owner(s)/Director(s))
Name
ID
DP
PP
Application Contact Person
Title
Proprietor
Managing Director
Type of Business (What Type of Products or Services does your Business Provide)
Business Contact
Business Address
Telephone Number
Mobile Number
Fax Number
Email
Personal Contact
Home Address
Telephone Number
Mobile Number
Email
Do you currently have a RBL personal or commercial Credit Card?
Yes
No
Account Number
Have you already built your online storefront?
Yes
No
Website URL
Potential Merchant Volume
Estimated Annual Sales Volumes
LINX Volumes
No. of Transactions
Credit Card Volumes
No. of Transactions
Republic Bank Limited Accounts
Branch
Type of Account
Account Number
Bank Contact Person
branch
acct
acct_num
contact
branch_2
acct_2
acct_num_2
contact_2
branch_3
acct_3
acct_num_3
contact_3
branch_4
acct_4
acct_num_4
contact_4
Other Bank Accounts
Branch
Type of Account
Account Number
Bank Contact Person
otherbranch_1
otheracct_1
otheracct_num_1
othercontact_1
otherbranch_2
otheracct_2
otheracct_num_2
othercontact_2
otherbranch_3
otheracct_3
otheracct_num_3
othercontact_3
otherbranch_4
otheracct_4
otheracct_num_4
othercontact_4
Would you be interested in other Merchant Facilities?
Yes
No
Select a Point Of Sale device
VISA/Master Card ONLY
LINX ONLY
VISA/Master Card/LINX
Submit
Leave this field blank
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