DocuSign Envelope ID: 24C91D41-4EEA-4A85-9054-A47EC873C174

LA ORANGE LIMITED
Jeton Business Merchant Application Form

Please complete the following information and provide it along with the supporting documentation. Kindly note that all relevant questions must be
completed. The Merchant Application Form should be signed by or on behalf of the Merchant. It is very important that the Merchant has read the
Application before signing as by signing the Application, the Merchant confirms that the details provided are correct and agrees to be bound by the
terms of the Agreement with La Orange Limited (‘Company’). If any question is not applicable to your business, please answer with “N/A”.

CONTACT DETAILS

Salutation: First Name: Last Name:

Nationality: Employee Position: Authorised Signatory: Y/N

Telephone Number: Email Address

COMPANY PROFILE

Merchant’s Legal Business Name (for Sole Ownerships, enter Principal’s Name): “Doing Business As/Trading as” Name:

Registered Address: City, State, Zip: Country:

Business Address/Trading Address (PO Boxes not accepted) – if different from the registered City, State, Zip: Country:
address:

Business Telephone: Business Email Address Contact Name:

Customer Service Phone: Company Registration No: Business Fax: Date of Incorporation:

VAT reg No. (or equivalent): Business Owner’s E-Mail (required):

Other Branches:

What is the nature of the business?

Please outline the businesses working capital and how income is generated.

Is the business regulated or licenced?

If yes, please provide URL or other evidence as applicable.

Does the entity have a website?

If yes, please provide link/s to website

1
LA ORANGE LIMITED
Registered in England Co. No. 11535714 at Floor 24/25 The Shard 32 London Bridge Street, London SE1 9SG
DocuSign Envelope ID: 24C91D41-4EEA-4A85-9054-A47EC873C174
LA ORANGE LIMITED
Jeton Business Merchant Application Form

BUSINESS PARTNERS

Please list the main business partners to whom payments will be made (we may require a copy of the business agreements at any time)

Customer’s main business partners from whom payments will be made (we may require a copy of the business agreements at any time)

EXPECTED ACCOUNT ACTIVITY QUESTIONNAIRE

1. Please provide a detailed explanation regarding the purpose of use of the IBAN account?

2. Please provide a detailed explanation on the underlying reason for incoming payments (please explain the flow of funds in detail)

3. Please provide a detailed explanation on the underlying reason for outgoing payments (please explain the flow of funds in detail)

4. What will be the source of funds into the account?

5. Which is your target business sectors?

6. Which are the main countries (top 10) you will process payments to? (Please provide a percentage breakdown of the countries in your last 12 months activity)

7. Which are the main countries (top 10) you will process payments from? (Please provide a percentage breakdown of the countries in your last 12 months activity)

8. Please provide a percentage breakdown of the countries in which your customers are based

9. Expected incoming transactions volume on a monthly basis

10. Expected outgoing transactions volume on a monthly basis

11. Expected incoming transactions value (EUR) on a monthly basis

12. Expected outgoing transactions value on a monthly basis)

13. Expected average amount of single incoming transactions in EUR

14. Expected average amount of single outgoing transactions in EUR

2
LA ORANGE LIMITED
Registered in England Co. No. 11535714 at Floor 24/25 The Shard 32 London Bridge Street, London SE1 9SG
DocuSign Envelope ID: 24C91D41-4EEA-4A85-9054-A47EC873C174
LA ORANGE LIMITED
Jeton Business Merchant Application Form

BUSINESS BANKING INFORMATION (EUR/GBP/USD)

Please provide details of your business bank accounts where funds may be sent to or received from

EUR - Bank Name: Account Holder Name: Date Account was opened:

Account No.: IBAN: SWIFT/BIC:

GBP - Bank Name: Account Holder Name: Date Account was opened:

Account No.: IBAN: SWIFT/BIC:

USD - Bank Name: Account Holder Name: Date Account was opened:

Account No.: IBAN: SWIFT/BIC:

Any Other Currency - Bank Name: Account Holder Name: Date Account was opened:

Account No.: IBAN: SWIFT/BIC:

DIRECTORS
Name: Title: Date of Birth: Nationality:
1.

Address: City: State/Country: Zip:

Name: Title: Date of Birth: Nationality:

2.

Address: City: State/Country: Zip:

Name: Title: Date of Birth: Nationality:

3.

Address: City: State/Country: Zip:

Name: Title: Date of Birth: Nationality:

4.

Address: City: State/Country: Zip:

Name: Title: Date of Birth: Nationality:

5.

Address: City: State/Country: Zip:

Name: Title: Date of Birth: Nationality:

6.

Address: City: State/Country: Zip:

3
LA ORANGE LIMITED
Registered in England Co. No. 11535714 at Floor 24/25 The Shard 32 London Bridge Street, London SE1 9SG
DocuSign Envelope ID: 24C91D41-4EEA-4A85-9054-A47EC873C174
LA ORANGE LIMITED
Jeton Business Merchant Application Form

Is your Company director another Company YES NO

Director Company’s Legal Business Name: “Doing Business As/Trading as” Name:

Registered Address: City, State, Zip: Country:

Business Address/Trading Address (PO Boxes not accepted) – if different from the registered City, State, Zip: Country:
address:

Business Telephone: Business Email Address Company Registration No:

Company Type: Industry:

If YES, please provide the names of the Directors of the Company that is a director of your Company (OPTIONAL ONLY IS THE ABOVE ANSWER IS YES)
Name: Title: Date of Birth: Nationality:
1.

Address: City: State/Country: Zip:

Name: Title: Date of Birth: Nationality:

2.

Address: City: State/Country: Zip:

Name: Title: Date of Birth: Nationality:

3.

Address: City: State/Country: Zip:

Name: Title: Date of Birth: Nationality:

4.

Address: City: State/Country: Zip:

Name: Title: Date of Birth: Nationality:

5.

Address: City: State/Country: Zip:

Name: Title: Date of Birth: Nationality:

6.

Address: City: State/Country: Zip:

BENEFICIAL OWNERS / TRUSTEES

(Beneficial Owners - Individual or entity owning/controlling 25% or more in Company shares/voting rights)

Name and Surname: Date of Birth: Nationality: Passport No

1.

Residence Address: City: State/Country: Zip:

Outline how current wealth has been generated: Economic Activity (source of income) Percentage of ownership Share Value

4
LA ORANGE LIMITED
Registered in England Co. No. 11535714 at Floor 24/25 The Shard 32 London Bridge Street, London SE1 9SG
DocuSign Envelope ID: 24C91D41-4EEA-4A85-9054-A47EC873C174
LA ORANGE LIMITED
Jeton Business Merchant Application Form

Name and Surname: Date of Birth: Nationality: Passport No

2.

Residence Address: City: State/Country: Zip:

Outline how current wealth has been generated: Economic Activity (source of income) Percentage of ownership Share Value

Name and Surname: Date of Birth: Nationality: Passport No

3.

Residence Address: City: State/Country: Zip:

Outline how current wealth has been generated: Economic Activity (source of income) Percentage of ownership Share Value

Name and Surname: Date of Birth: Nationality: Passport No

4.

Residence Address: City: State/Country: Zip:

Outline how current wealth has been generated: Economic Activity (source of income) Percentage of ownership Share Value

Name and Surname: Date of Birth: Nationality: Passport No

5.

Residence Address: City: State/Country: Zip:

Outline how current wealth has been generated: Economic Activity (source of income) Percentage of ownership Share Value

Name and Surname: Date of Birth: Nationality: Passport No

6.

Residence Address: City: State/Country: Zip:

Outline how current wealth has been generated: Economic Activity (source of income) Percentage of ownership Share Value

Is your Company owned by another Company YES NO

5
LA ORANGE LIMITED
Registered in England Co. No. 11535714 at Floor 24/25 The Shard 32 London Bridge Street, London SE1 9SG
DocuSign Envelope ID: 24C91D41-4EEA-4A85-9054-A47EC873C174
LA ORANGE LIMITED
Jeton Business Merchant Application Form

Director Company’s Legal Business Name: “Doing Business As/Trading as” Name:

Registered Address: City, State, Zip: Country:

Business Address/Trading Address (PO Boxes not accepted) – if different from the registered City, State, Zip: Country:
address:

Business Telephone: Business Email Address Company Registration No:

Company Type: Industry:

If YES, please provide the names of the UBOs of the Company that owns your Company: (OPTIONAL ONLY IS THE ABOVE ANSWER IS YES)

Name and Surname: Date of Birth: Nationality: Passport No

1.

Residence Address: City: State/Country: Zip:

Outline how current wealth has been generated: Economic Activity (source of income) Percentage of ownership Share Value

Name and Surname: Date of Birth: Nationality: Passport No

2.

Residence Address: City: State/Country: Zip:

Outline how current wealth has been generated: Economic Activity (source of income) Percentage of ownership Share Value

Name and Surname: Date of Birth: Nationality: Passport No

3.

Residence Address: City: State/Country: Zip:

Outline how current wealth has been generated: Economic Activity (source of income) Percentage of ownership Share Value

Name and Surname: Date of Birth: Nationality: Passport No

4.

Residence Address: City: State/Country: Zip:

6
LA ORANGE LIMITED
Registered in England Co. No. 11535714 at Floor 24/25 The Shard 32 London Bridge Street, London SE1 9SG
DocuSign Envelope ID: 24C91D41-4EEA-4A85-9054-A47EC873C174
LA ORANGE LIMITED
Jeton Business Merchant Application Form

Outline how current wealth has been generated: Economic Activity (source of income) Percentage of ownership Share Value

Name and Surname: Date of Birth: Nationality: Passport No

5.

Residence Address: City: State/Country: Zip:

Outline how current wealth has been generated: Economic Activity (source of income) Percentage of ownership Share Value

Name and Surname: Date of Birth: Nationality: Passport No

6.

Residence Address: City: State/Country: Zip:

Outline how current wealth has been generated: Economic Activity (source of income) Percentage of ownership Share Value

AUTHORISED SIGNATORIES

Name: Title: Date of Birth: Nationality:

1.

Address: City: State/Country: Zip:

Name: Title: Date of Birth: Nationality:

2.

Address: City: State/Country: Zip:

Name: Title: Date of Birth: Nationality:

3.

Address: City: State/Country: Zip:

Name: Title: Date of Birth: Nationality:

4.

Address: City: State/Country: Zip:

Name: Title: Date of Birth: Nationality:

5.

Address: City: State/Country: Zip:

7
LA ORANGE LIMITED
Registered in England Co. No. 11535714 at Floor 24/25 The Shard 32 London Bridge Street, London SE1 9SG
DocuSign Envelope ID: 24C91D41-4EEA-4A85-9054-A47EC873C174
LA ORANGE LIMITED
Jeton Business Merchant Application Form

Name: Title: Date of Birth: Nationality:

6.

Address: City: State/Country: Zip:

KYC/KYB DOCUMENTS REQUIRED

You will find the full list of documentation required when going through the merchant on-boarding process on our website.

N.B. – Additional documentation may be requested by La Orange Limited at any point during the onboarding phase after the
application has been submitted.

DECLARATION:

Have you or any other directors, shareholders, ultimate beneficiary owners or other persons connected with the business mentioned in this
application form ever received a criminal conviction/prosecution or have any convictions/prosecutions pending (other than minor traffic offenses,
not involving prison)?

Yes No
(if yes, please provide details):

Are there any ongoing investigations or inquiries by or on behalf of any government or other body in respect of the affairs of your company, and any
of its subsidiaries or parent company?

Yes No
(if yes, please provide details):

Has the company received cautions, fines or been banned from operating within any jurisdiction?

Yes No
(if yes, please provide details):

Please note, we can keep partial applications pending for 90 days from first submission, after which a new application with up to date documentation
may be required. This limit does not affect approved/conditionally approved applications awaiting technical integration.

DISCLAIMER
By signing this form, you consent and confirm that all the individuals set out above have consented and grant us and any third parties we work with
permission to make any enquiries with any third party we consider necessary to verify any information provided to us. This may include obtaining,
checking and/or reviewing applicable credit reports and/or commercial registers or databases. A credit check will leave a soft footprint on the
individual’s credit history. Upon signing a agreement with us, you will be obliged to further consent and confirm that the above listed individuals
further consent to the personal data being processed in accordance with the terms of the applicable agreement.

Please be advised that La Orange Limited reserves the right to request all the documents requested in this document, as part of our on-going
obligations under the Laws of England to complete verification on all our on-going and prospective business partners. We would use verification/
credit reference agencies to verify the information submitted herein.

The information provided on this form will be processed for the purposes necessary for La Orange Limited to carry out its functions and meet its
legal obligations. The data may be shared with third parties which fulfil a service on behalf of and under the express instructions of La Orange Limited
and other bodies where it is necessary to do so in order to carry out the Company’s functions and where La Orange Limited is legally required or
permitted to do so.

Any material or information which you send us and which we record will be treated as confidential and will only be disclosed to others where it is
necessary to do so in order to carry out functions or where required by law to disclose the information.
Your application will not be considered unless all relevant questions have been completed and the required documents submitted in full. Should
you fail to submit all the documents listed then this may delay the integration of your services with our Company.
 We hereby certify that this document and the contents stated within it are an accurate account of our company structure and financial
position as it currently stands.
 We also certify that should any of the information stated herein is later found to be untrue, we will notify La Orange Limited as soon as
reasonably possible.

8
LA ORANGE LIMITED
Registered in England Co. No. 11535714 at Floor 24/25 The Shard 32 London Bridge Street, London SE1 9SG
DocuSign Envelope ID: 24C91D41-4EEA-4A85-9054-A47EC873C174
LA ORANGE LIMITED
Jeton Business Merchant Application Form

SIGNATURE ‘I confirm that the information provided in this application form is correct to the best of my knowledge.’

Authorised Signature:

THIND DISPATCHER
Print Name:

tahalatif74@gmail.com
Contact email:

Position/Relationship to the company (if not mentioned elsewhere) Please provide proof of authorisation if not appointed as a director.

Date of signature:

9
LA ORANGE LIMITED
Registered in England Co. No. 11535714 at Floor 24/25 The Shard 32 London Bridge Street, London SE1 9SG
Certificate Of Completion
Envelope Id: 24C91D414EEA4A859054A47EC873C174 Status: Delivered
Subject: Please DocuSign: MAF_J-business docusign version_14December2020.docx
Source Envelope:
Document Pages: 9 Signatures: 0 Envelope Originator:
Certificate Pages: 4 Initials: 0 Urus London Limited (Jeton)
AutoNav: Enabled LA Orange Limited
EnvelopeId Stamping: Enabled The Shard Floor 24/25, 32 London Bridge Street
Time Zone: (UTC-08:00) Pacific Time (US & Canada) London, GB-LND SE1 9SG
kam@jeton.com
IP Address: 54.154.46.122

Record Tracking
Status: Original Holder: Urus London Limited (Jeton) Location: DocuSign
6/4/2023 5:15:53 PM kam@jeton.com

Signer Events Signature Timestamp

THIND DISPATCHER Sent: 6/4/2023 5:15:55 PM
tahalatif74@gmail.com Viewed: 6/4/2023 5:16:27 PM
Security Level:
.Password
ID: 1b0b3854-f882-4fbe-9637-032888034671
6/4/2023 5:15:56 PM
Electronic Record and Signature Disclosure:
Accepted: 6/4/2023 5:16:27 PM
ID: e008278f-4955-4c88-93b6-e6e801f2e66d

In Person Signer Events Signature Timestamp

Editor Delivery Events Status Timestamp

Agent Delivery Events Status Timestamp

Intermediary Delivery Events Status Timestamp

Certified Delivery Events Status Timestamp

Carbon Copy Events Status Timestamp

Witness Events Signature Timestamp

Notary Events Signature Timestamp

Envelope Summary Events Status Timestamps

Envelope Sent Hashed/Encrypted 6/4/2023 5:15:55 PM
Certified Delivered Security Checked 6/4/2023 5:16:27 PM

Payment Events Status Timestamps

Electronic Record and Signature Disclosure
Electronic Record and Signature Disclosure created on: 10/14/2019 6:27:47 AM
Parties agreed to: THIND DISPATCHER

ELECTRONIC RECORD AND SIGNATURE DISCLOSURE

From time to time, Jeton (we, us or Company) may be required by law to provide to you certain
written notices or disclosures. Described below are the terms and conditions for providing to you
such notices and disclosures electronically through the DocuSign system. Please read the
information below carefully and thoroughly, and if you can access this information electronically
to your satisfaction and agree to this Electronic Record and Signature Disclosure (ERSD), please
confirm your agreement by selecting the check-box next to ‘I agree to use electronic records and
signatures’ before clicking ‘CONTINUE’ within the DocuSign system.

Getting paper copies

At any time, you may request from us a paper copy of any record provided or made available
electronically to you by us. You will have the ability to download and print documents we send
to you through the DocuSign system during and immediately after the signing session and, if you
elect to create a DocuSign account, you may access the documents for a limited period of time
(usually 30 days) after such documents are first sent to you. After such time, if you wish for us to
send you paper copies of any such documents from our office to you, you will be charged a
$0.00 per-page fee. You may request delivery of such paper copies from us by following the
procedure described below.

Withdrawing your consent

If you decide to receive notices and disclosures from us electronically, you may at any time
change your mind and tell us that thereafter you want to receive required notices and disclosures
only in paper format. How you must inform us of your decision to receive future notices and
disclosure in paper format and withdraw your consent to receive notices and disclosures
electronically is described below.

Consequences of changing your mind

If you elect to receive required notices and disclosures only in paper format, it will slow the
speed at which we can complete certain steps in transactions with you and delivering services to
you because we will need first to send the required notices or disclosures to you in paper format,
and then wait until we receive back from you your acknowledgment of your receipt of such
paper notices or disclosures. Further, you will no longer be able to use the DocuSign system to
receive required notices and consents electronically from us or to sign electronically documents
from us.

All notices and disclosures will be sent to you electronically

Unless you tell us otherwise in accordance with the procedures described herein, we will provide
electronically to you through the DocuSign system all required notices, disclosures,
authorizations, acknowledgements, and other documents that are required to be provided or made
available to you during the course of our relationship with you. To reduce the chance of you
inadvertently not receiving any notice or disclosure, we prefer to provide all of the required
notices and disclosures to you by the same method and to the same address that you have given
us. Thus, you can receive all the disclosures and notices electronically or in paper format through
the paper mail delivery system. If you do not agree with this process, please let us know as
described below. Please also see the paragraph immediately above that describes the
consequences of your electing not to receive delivery of the notices and disclosures
electronically from us.

How to contact Jeton:

You may contact us to let us know of your changes as to how we may contact you electronically,
to request paper copies of certain information from us, and to withdraw your prior consent to
receive notices and disclosures electronically as follows:
To contact us by email send messages to: legal@jeton.com

To advise Jeton of your new email address

To let us know of a change in your email address where we should send notices and disclosures
electronically to you, you must send an email message to us at legal@jeton.com and in the body
of such request you must state: your previous email address, your new email address. We do not
require any other information from you to change your email address.

If you created a DocuSign account, you may update it with your new email address through your
account preferences.

To request paper copies from Jeton

To request delivery from us of paper copies of the notices and disclosures previously provided
by us to you electronically, you must send us an email to legal@jeton.com and in the body of
such request you must state your email address, full name, mailing address, and telephone
number. We will bill you for any fees at that time, if any.

To withdraw your consent with Jeton

To inform us that you no longer wish to receive future notices and disclosures in electronic
format you may:
i. decline to sign a document from within your signing session, and on the subsequent page,
select the check-box indicating you wish to withdraw your consent, or you may;

ii. send us an email to legal@jeton.com and in the body of such request you must state your
email, full name, mailing address, and telephone number. We do not need any other information
from you to withdraw consent.. The consequences of your withdrawing consent for online
documents will be that transactions may take a longer time to process..

Required hardware and software

The minimum system requirements for using the DocuSign system may change over time. The
current system requirements are found here: https://support.docusign.com/guides/signer-guide-
signing-system-requirements.

Acknowledging your access and consent to receive and sign documents electronically

To confirm to us that you can access this information electronically, which will be similar to
other electronic notices and disclosures that we will provide to you, please confirm that you have
read this ERSD, and (i) that you are able to print on paper or electronically save this ERSD for
your future reference and access; or (ii) that you are able to email this ERSD to an email address
where you will be able to print on paper or save it for your future reference and access. Further,
if you consent to receiving notices and disclosures exclusively in electronic format as described
herein, then select the check-box next to ‘I agree to use electronic records and signatures’ before
clicking ‘CONTINUE’ within the DocuSign system.

By selecting the check-box next to ‘I agree to use electronic records and signatures’, you confirm
that:

 You can access and read this Electronic Record and Signature Disclosure; and
 You can print on paper this Electronic Record and Signature Disclosure, or save or send
this Electronic Record and Disclosure to a location where you can print it, for future
reference and access; and
 Until or unless you notify Jeton as described above, you consent to receive exclusively
through electronic means all notices, disclosures, authorizations, acknowledgements, and
other documents that are required to be provided or made available to you by Jeton
during the course of your relationship with Jeton.