By signing below, I represent that I am authorized to disclose the information and provide the consents contained in this Application, and to sign this Application on behalf of the above-referenced entity(ies) (the “Applicant”). I further represent that all the information in this Application is true, complete, and accurate. I authorize ConnexPay and its agents to verify the information in this Application and receive and exchange information from reporting agencies, where necessary to assess the Applicant for the use of the Payment Services. On behalf of Applicant, I acknowledge that this application is subject to approval by ConnexPay and its Bank, and that Applicant must agree to the terms of the ConnexPay Payment Services Agreement.