FORM PERMOHONAN MERCHANT

Dokumen/Persyaratan yang harus dilampirkan

• Copy KTP direksi/pengurus perusahaan dan atau copy KTP penerima kuasa dari pengurus (merchan
• Copy KTP pemilik usaha/nama yang tertera dalam SIUP/nama yang tertera dalam Akte (merchant pe
• Anggaran Dasar (dari akta pendirian dan perubahan terakhir)
• Pengesahaan/Persetujuan dari instansi berwenang/lembar Negara
• Surat Ijin Usaha Perdagangan (SIUP)
• Tanda Daftar Perusahaan (TDP)
•• NPWP

Bank tidak akan menerima aplikasi dari pihak yang terlibat di salah satu, layanan dibawah ini seperti prod
dan kegiatan atau produk jasa dan kegiatan yang melawan hukum :
- Pornography & Adult Content
- Firearms, Ammunition, High Capacity Magazines, Tasers, Air Guns
- Fireworks or Pyrotechnic Devices or Supplies
- Unapproved Drugs
- Gambling Transactions / Online Casino
- Replica and Name Brand "Knock Off" Products
- Tele-sales
- Money laundering
- Pyramid Scheme Program

Jika website diketahui menjual produk atau jasa terlarang di atas maka akun akan segera dihapus.
Pembekuan deposit, penghangusan deposit, denda, dan/atau pembatalan pemesanan, dilakukan tanpa pemberitahuan.
FORM PERMOHONAN MERCHANT e-Commerce

A Data Merchant

Nama Merchant : ___________________________________________________________________

Alamat Merchant : ___________________________________________________________________

Kota : _________________________ Kode Pos :

Provinsi : _________________________ Negara :

No. Telephone : _________________________ No. Fax :

 Tanggal Berdiri :

Bentuk Badan Usaha Pribadi CV PT

Status Tempat Usaha Milik Sendiri Milik Keluarga Sewa/Kontrak sampai tanggal ______________

No. Registrasi Perush ______________________________________________________________________

(SIUP/TDP/Akte/………...) (pilih salah satu)

No. NPWP ____________________________ Atas Nama ____________________________

Jumlah Karyawan ____________________________ Corp Website ____________________________

Area Pemasaran Domestik Internasional

Produk/servis dijual ______________________________________________________________________

Total Sales Bulanan ______________________________________________________________________

Jenis Pembayaran Semua Kartu Kredit Int Banking

Ada bukti kirim/bayar? Tidak Ya

Memiliki Kebijakan Tidak Ya

Pengembalian?

Pilihan pembayaran yang ingin dibuka :

CIMB Clicks Rekening Ponsel

B Data Usahawan (sesuai KTP)

Nama ______________________________________________________________________

Alamat ______________________________________________________________________

Kota ____________________________ Kode Pos ______________________________

Provinsi ____________________________ Negara ______________________________

No. KTP ______________________________________________________________________

Jabatan _______________________________________________________________________

Status Domisili Tinggal Milik Sendiri Milik Keluarga Sewa/Kontrak sampai tanggal ______________

No. Telephone Telp. Rumah : ________________________ No.HP :____________________________

Email ________________________________________________________

C Contact Person Bisnis

Nama ______________________________________________________________________

Jabatan ______________________________________________________________________

No. Telephone ____________________________ No. Fax _______________________________

Email ____________________________
D Hubungan Dengan Bank (jika ada sebelumnya)

Admin Fee __________________ (________________________________________)

No. Rek CIMB Niaga ____________________________

Atas Nama ____________________________

Cabang ____________________________

Nasabah Sejak ____________________________

E Kerjasama Dengan Bank Lain

Nama Bank Admin Fee

_____________________ ___________
_____________________ ___________
_____________________ ___________
_____________________ ___________
_____________________ ___________

Tanda Tangan Pemohon dan Stempel Perusahaan Pengesahan Petugas Bank

Nama _____________________ Nama

Jabatan _____________________ Jabatan
Tanggal _____________________ Tanggal
enerima kuasa dari pengurus (merchant perusahaan)
a yang tertera dalam Akte (merchant perorangan)

h satu, layanan dibawah ini seperti produk

n, dilakukan tanpa pemberitahuan.

 Paraf

No.

_________________________________

_________________________________

___________________________

___________________________

___________________________
 TBK Lainnya______________

sampai tanggal __________________________

_________________________________

______________________________

______________________________

_________________________________

_________________________________

Lainnya ___________________________

____________________________

____________________________

______________________________

______________________________

____________________________

_____________________________

sampai tanggal _______________________

No.HP :____________________________
______________________

____________________________

____________________________

______________________________________

Paraf
______________________)

Pengesahan Petugas Bank

_____________________
_____________________
_____________________
Paraf
Form Teknis Merchant
Merchant Name :
Terminal ID Name :
Date :

Intended Live Date :

Description Response

Note : Italic & red is fill in by Merchant

1 Merchant Name Name :

2 Merchant Address Address :

Telp No. :

2 Open for Channel Payment CIMB Clicks

3 CIMB Clicks Limit

Max Limit per Transaction Please fill in this section with max limit per transaction allowed
Max Limit per Transaction :

Max Limit per Day Please fill in this section with max limit per day allowed (if nee
Max Limit per Day :

4 Rekening Ponsel Limit

Max Limit per Transaction Please fill in this section with max limit per transaction allowed
Max Limit per Transaction :

Max Limit per Month Please fill in this section with max limit per day allowed (if nee
Max Limit per Day :

5 Technical Contact Person Name :

Title :
 Email :
Mobile No. :
YM ID (if any) :
Other messanger ID (if any) :

6 Payment notification customer will be 1.

sent to... (max 5 merchant's email) 2.
3.
4.
5.

7 Contact person for complain handling Phone no. :

(Call Center) Fax no. :
Email :

8 Test Account Request
Please fill up this section if test account is requested.
Purpose: _______________________________________
Start Date: _______________________________________
End Date: _______________________________________
Assigned by: _______________________________________
9 Pre-requisite and Merchant Expectation on Before integration commencement please ensures the guidelin
Integration 1. Please register request URL
Request URL :
-------------------------------------------------------------
2. Registered request URL must be either IP or domain based
Note: LocalHost is not allowed.
3. Testing transaction must from registered URL.
4. Test transaction with amount IDR 3.000,00.
5. Test transaction with credit card ONLY.
6. Response URL can be set in request page with ResponseUR
Response URL :
-------------------------------------------------------------
7. Backend post URL can be set in request page with Backend
8. Email notification is NOT guarantee as it ISP dependant.

10 Technical Competencies Integration Competencies Required (at least one)

Programming Language
ASP.Net
PHP
ASP
Java

Database
MySQL
MS SQL

Others skill set

XML or Webservice

11 Integration Info Please fill up this section

Integration Start Date : ...............................
Integration End Date : ...............................
Target Live Date : ...............................
Staging/Test URL : ..............................................................
Production URL : ..............................................................
Merchant Technical contact no : ...............................
Merchant Technical email : ...............................
E2Pay Integration contact : ...............................

12 Implemented e2pay feature Please specific implemented feature in merchant system

Standard re-query
Webservice re-query
Backend post
Signature (via web services)
13 Customisation Requirement If yes, please specify

Landing Pages showing Merchant’s Name (Logo)

If Yes, please provide logo, the maximum allow size for th
600 pixel (width) by 100 pixel (height) and
the allow format are JPG, BMP, and GIF.
Report Requirement
Others, please specify

<please
Rekening provide
Ponsel requirement document>
15 Name PIC CIMB Niaga : ___________________

Merchant id :________________________ (3 caracter)

( Fill by Bank)
User Id :________________________
CIMB Clicks

Paye Code :_______________________

Signoff and Submitted by :

____________________
Signature :
Name :
Designation:
Date :
 (in 8 caracter & Di isi oleh PIC CIMB Niaga)

Response

Rekening Ponsel

n with max limit per transaction allowed (if needed)

n with max limit per day allowed (if needed) Max.IDR 9 Milyar /day/CIF

n with max limit per transaction allowed (if needed) IDR 5 Juta/day

n with max limit per day allowed (if needed) IDR 20 Juta /month
 n if test account is requested.
____________________________________
____________________________________
_____________________________________
_____________________________________
 mencement please ensures the guidelines below are adhered.
est URL

------------------------------------
URL must be either IP or domain based.
allowed.
must from registered URL.
h amount IDR 3.000,00.
h credit card ONLY.
e set in request page with ResponseURL field or provided on below.

------------------------------------
an be set in request page with BackendURL field.
NOT guarantee as it ISP dependant.

ies Required (at least one)

e

on
...............................
...............................
........................
.........................................................
......................................................
ntact no : ...............................
mail : ...............................
act : ...............................

ented feature in merchant system

vices)
g Merchant’s Name (Logo)
ide logo, the maximum allow size for the logo is
y 100 pixel (height) and
e JPG, BMP, and GIF.

ement document>

_________________ (3 caracter)

_________________

________________