Merlin
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EXPLOITATION RETAINER SERVICES APPLICATION
1. Company Information
| Company Name
| Type of Business | Since | |
| Trade Name | Description of Exploitation The Company Engages In
| ||
| Limited Company ____ Partnership ____ Proprietorship ____ Not For Profit ____ Multinational ____ | Jurisdiction Of Company Registration State/Prov Country
| GST/Tax ID Number | |
| Web Address | City
| Prov/State
| |
| Primary Contact Name | Country
| Postal Code | |
| Phone Number
| Fax Number | Primary Contact Email | |
2. Ownership Information
Provide complete information for all those with more than 20% ownership. Use additional sheets if necessary.
| Name | Date of Birth | Citzenship | SSN / SIN
| ||
| Current Street Address
| City | Prov/State | Zip/Postal Code | ||
3. Business Information
| Estimated Gross Monthly Income? | $ |
| What is the average amount of each sale? | $ |
| What is the largest anticipated amount for each sale? | $ |
| How many days between the transaction date and the shipping date? |
|
| Company Financial Statements | Enclosed ____ Mailed ____ |
| Please check your delivery methods (required): ____ The majority of our goods are physical goods or services which will be delivered to the purchaser. ____The majority of our goods are physical goods or services which are available in retail outlets. ____The majority of our goods are electronic or intellectual goods delivered by internet, TV or other media. * I reserve the right to verify the above methods on a periodic basis. | |
Exploitation Retainer Configuration
All transactions by Electronic Funds Tranfer deposited directly into my account for your convenience. Check all that apply.
| Package | Setup | Monthly | Transaction Fee |
| ____ Basic Services, Generic | $99 | $69.99 | $0.74 |
| ____ Extended Services Package | $99 | $69.99 | $0.39 |
| ____ Exposure To Various Media | $99 | $69.99 | $0.29 |
| ____ Exposure To Media, Child, Each | $99 | $999.99 | $9.99 |
| ____ Any Form of Privatized Health Care | $99 | $1,499.99 | $69.99 |
| ____ Telephone Harassment | $99 | $69.99 | $99.00 |
| ____ GM Foods, Patented Life Forms | $99 | $499.99 | $19.99 |
| ____ Human Genome and Related | $99 | $499.99 | $44.99 |
| ____ Environmental Degradation (includes Global Warming & Nuclear Energy) | $99 | $1,499.99 | $144.99 |
| ____ War, Of Any Kind, On Any Scale | $999 | $9,999.99 | $999.99 |
I/we authorize Your Name Here to debit my/our credit card or my/our bank account for all charges as selected above. All ongoing and service charges will be debited from my/our bank as listed below. I agree to paying the Setup Fee at the time this application is ‘Approved’. I authorize Your Name Here to charge my/our credit card for any outstanding fees in the event that funds cannot be debited from my/our bank account.
PLEASE COMPLETE ALL FIELDS Pay Setup Fee from ___ bank account ___ credit card
| Payment Method Visa ____ Mastercard ____ | Card Number | Cardholder Name |
|
Bank Account ____ (Attach Void Cheque) | Bank Name | Bank Address |
| Transit Number
| Bank Account Number | Bank Account Name |
|
| Signature | |
8. Agreement
The undersigned declares that the statements herein are for the express purpose of obtaining permission to retain Your Name Here for the purposes of exploitation that will not cause him to come into harm's way or endanger his life, health, mental well being, etc, and are to the best of my/our knowledge and belief, true and correct. The applicant understands that additional information may be required before consideration can be given to this application. The applicant consents to having Your Name Here make any inquiries of such persons, firms, government bodies, NGO’s or corporations as he deems necessary in order to reach a decision on this application.
The undersigned also confirms by signing that they have read and understand all Terms and Conditions contained or implied by this contract, and agrees by signing to abide by these Terms and Conditions.
______________________________ _____________________________ ____________
Applicant’s Signature Authorized Name Date
