Stripe Payment Gateway - Client Questionnaire

1
To allow for online sales we will require the following information to set up a payment gateway account on your behalf. (This is a regulatory requirement)
2
Name of person completing this form* This field is required.
First Name
Last Name
3
Email address of person completing this form* This field is required.
example@example.com
Email Verified
The verification code has been sent to some@email.com
Please check your mailbox and paste the code below to complete verification
••••
Didn't receive verification code?or
Receiving the email may take a few minutes, thank you for your patience!
4
Registered Business Address* This field is required.
Street Address
Street Address Line 2
City
State
Post Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Business Phone Number* This field is required.
Area Code
Phone Number
6
Type of Business* This field is required.Please select one
Company
Partnership
Trust
Individual / Sole Trader
Not-for-Profit (NFP)
7
Business structure* This field is required.Please select one
Proprietary company
Public Company
8
Business structure ABN yes or No* This field is required.
I have an Australian business number (ABN)
I do not have an ABN
9
Business structure Not-for-Profit
Incorporated association
Unincorporated association
Cooperative
Other
10
Provide ABN and ACN if applicable* This field is required.
Legal Business name
Australian business number (ABN)
Australian company number (ACN)
Doing Business as (Optional)
11
Business representative* This field is required.This account must be activated by an executive, senior manager or someone who otherwise has significant responsibility for the control and management of your business. If that’s not you, please ask the right person to fill out this form.
Legal First name of person
Legal Last name of person
Home address
Phone Number
Email addess
Job Title
DOB Date of birth
12
Product description* This field is required.In a sentence or two, tell us what products or services you provide, and when you charge your customers (such as during checkout or three days later). This helps us understand your business and process your application quickly.
Product or Service Description
13
Business owners* This field is required.Due to regulatory guidelines, we’re required to collect information on anyone who has significant ownership of your business. "Please add any individual who owns 25% or more of the company."
14
Business Directors* This field is required.We are required to collect information about all directors of the company
15
Business Executives* This field is required.We’re required to collect information about any executives or senior managers who have significant management responsibility for this business.
16
Statement descriptor* This field is required.A statement descriptor is the business name a customer will see on their card statements. Choose a name that’s at least five characters and easy to recognise to avoid potential chargebacks.
17
Shortened descriptor* This field is required.You may provide more specific details about a charge with dynamic suffixes. When a suffix is used, it is combined with the shortened descriptor on card statements.
18
Customer support phone number* This field is required.Number customer can contact for payment issues.
Area Code
Phone Number
19
Provide Bank BSB number for payouts* This field is required.BSB Number
20
Provide Bank account for payouts* This field is required.Bank Account Number
21
Signature of person submitting the form* This field is required.We use Stripe or a service connected to Stripe to process payments on your site. I agree to allow Clever Dog Design personnel to register a Stripe or Stripe linked account with the above details on my behalf. I agree to this Direct Debit Request and the Direct Debit Request Service Agreement, and authorise Stripe Payments Australia Pty Ltd (ACN 160 180 343, Direct Debit User ID number 507156, “Stripe”) to debit my account through the Bulk Electronic Clearing System (BECS) in the event that the net activity in my Stripe account on any day is negative or for any other reason relating to the Stripe Services. I certify that I am either an account holder or an authorised signatory on the account listed above.
Clear
22

Phew, Good work! You're finished!

All the Clever Dogs appreciate your efforts and all this

information will help us to make a fantastic site for you.

You may hear back from us shortly if we have any further questions.

If you wish to discuss any part of this submission don't hesitate

to contact us on 07 3188 5164

Now just sign the following page and press the submit button

and we'll be on our way.
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