1—Applicant Information
Legal Name of Applicant:
Abbreviated Name(s):
“Doing Business As” Name:
Indicate Worldwide Subsidiaries:
List all Former Legal Names of Applicant:
Website Address (URL):
Registered Address (Legal Headquarters Address)
Street Address: / Town/City:
State/Country: / ZIP/Postal Code:
Phone: / Fax:
Mailing Address (if different from Registered Address above)
Complete for each country within which you are applying for a license.
Street Address: / Town/City:
State/Country: / ZIP/Postal Code:
Phone: / Fax:
Principal Contact of applicant Details
Mr./Ms.: / Name:
Title/Position: / Phone:
Fax: / E-mail:
Senior Executive Details – Includes CEO and all direct reports (attach additional sheets)
Mr./Ms.: / Name:
Title/Position: / Phone:
Fax: / E-mail:
Anti-Money Laundering Contact Details
Mr./Ms.: / Name:
Title/Position: / Phone:
Fax: / E-mail:
Legal Contact Details
Mr./Ms.: / Name:
Title/Position: / Phone:
Fax: / E-mail:
2— Details About Applicant’s Organization
Type of Institution:
Are you a deposit-taking Institution? / Yes No
Describe the principal lines of business, major customer segments and geographic locations:
Name of Ultimate Owner of Institution:
Describe changes in corporate organization within the past 12 months (e.g. sold subsidiary, new affiliate, change
in senior management, owners or Board of Directors):
Number Branches: / Number of Employees:
States where Branches are registered or incorporated:
Number of Current Accounts: / Number of Deposit Accounts:
Equity capital for previous quarter (in USD):
Total assets for previous quarter (in USD):
Institution (R&T) Number(US applicants only):
Processor’s Name: / Processor Number:
Federal Reserve Bank (FRB) ID Number (US/US Territory applicants only):
VAT Number (European applicants only):
Are shares of the applicant’s institution publicly traded? / Yes No
If yes: Start Date: / Stock Exchange:
Please complete the charts on the following page. List each individual or legal entity owning 20% or greater interest in the Applicant and indicate if any portion of the Applicant’s business is owned by a Government.
Note: Holding company names and shell corporations (“nominees”) are not acceptable ownership information.
Also, provide all requested information for each individual having management and/or control of the Applicant’s business.
Note: If additional lines are necessary, please attach a separate sheet to this application.
Ownership – Individuals
First Name / Second Name / Last Name / Address / Year of Birth / Country of Birth / % of Ownership
Ownership – Legal Entities
Entity Name* / Entity DBA and/or abbreviated name(s) / Street Address / % of Ownership
*if part of a group, please provide group structure including shareholder information
Control and ExecutivesFirst Name / Second Name / Last Name / Street Address / Year of Birth / Country of Birth / Years with Company / Years with Industry
CEO (or equivalent title)
Executive Level Management (direct reports to CEO)
Board of Directors
2—Details About Applicant’s Organization (continued)
Is Applicant required to comply with AML or anti-terrorist financing legislation? / Yes No
If yes,
a) Indicate the applicable laws and regulations:
b) Does Applicant currently have an AML Policy and Program designed to prevent money laundering and terrorist financing? / Yes No
c) Has this policy been deemed adequate by Applicant’s regulatory supervisor? / N/A – not
regulated or supervised. / Yes No
If yes,
As of when and by whom?
Were there any negative findings?
How/when were negative findings resolved?
Is there any legislation in place requiring shareholders to obtain regulatory approval before they can become significant shareholders? / Yes No
Is applicant an offshore institution? (An offshore institution is an entity incorporated in a country where it is not allowed to deal in local currency or with local residents.) / Yes No
Is applicant a shell bank; that is, an institution without a physical presence in any country? (For this purpose, “physical presence” means a place of business maintained by the bank; that the bank is located at a fixed address in the country in which the bank is authorized to conduct banking activities; it employs at that location one or more full-time individuals; it maintains at that location operating records related to banking activities; and it is subject to inspection by the banking authority which licensed the bank to conduct banking activities.) / Yes No
If yes: Is applicant a subsidiary of a depository institution, credit union, or bank that maintains a physical presence and is subject to supervision by a banking authority? / Yes No
Is the applicant’s policy to prohibit relationships with shell banks? / Yes No
If no, please explain:
Country(ies) where regulated:(attach additional sheets if necessary):
Regulatory agency(ies) governing card activity (complete for each country within which you are applying for a license):
Regulatory agency(ies) that supervises applicant regarding financial condition (complete for each country within which you are applying for a license):
Chartering agency(ies) (Chartering agency is the governmental agency that gives the institution the right to do business as a financial institution, whether as a bank, credit union, credit card company, building society, etc.):
2—Details About Applicant’s Organization (continued)
Is applicant still regulated by its chartering or regulatory agency(ies)? / Yes No
If no, please explain:
Has applicant ever been the subject of any official government enforcement action or investigation, either currently or in the past? / Yes No
If yes, please explain:
3—Participation Requested
Note: If applicant is applying to use a brand in more than one country, please copy and complete Sections 4–9 for eachadditional country requested.
Indicate Brand License, Area of Use (country), Participation Level and Type(s) of Activity being requested:
MasterCard / MasterCard Electronic / MasterCard Cash / Maestro / Cirrus
Country: / Country: / Country: / Country: / Country:
Principal / Principal / Principal / Principal / Principal
Affiliate / Affiliate / Affiliate / Affiliate / Affiliate
Association / Association
Issuing and Acquiring Merchants and ATM* / Issuing and Acquiring Merchants and ATM* / Issuing and Acquiring Merchants / Issuing and Acquiring Merchants and ATM* / Issuing and Acquiring ATM*
Acquiring Merchants and ATM* / Acquiring Merchants and ATM* / Acquiring Merchants / Acquiring Merchants and ATM* / Acquiring ATM*
Cash Advance (Teller) / Cash Advance (Teller) / AP Region Only
Issuing Only Card Activities
*Upon being granted a license to use any one of the MasterCard, Maestro or Cirrus Marks, Applicant shall also be granted a limited license to acquire MasterCard, Maestro and Cirrus transactions at ATMs operated or sponsored by Applicant in accordance with the applicable Rules and to display the MasterCard, Maestro, and Cirrus Marks at such ATMs.
US and US Territory applicants only - for Debit and Prepaid programs:
The Durbin Amendment to the Dodd-Frank Wall Street Reform and Consumer Protection Act requires MasterCard to identify your Durbin Rate. Please indicate below your qualified debit interchange rate.
Regulated / Non-regulated / Adjusted-regulated
For MasterCard affiliate applicants to be sponsored by a Third Party Processor (TPP) (U.S. Only), indicate the type of BIN program code(s) being requested.(Note: Refer to the ICA/BIN Request (Form 658f U.S.) for available program codes.)
Debit Program Code(s): / Credit Program Code(s):
If more than two BINs are being requested for this program, the ICA/BIN Request (Form 658f) must also be submitted.
If a MasterCard affiliate applicant, will you own or control cardholder and/or merchant agreements? / Yes / No
3—Participation Requested (continued)
For Cirrus licenses, list all EFT Systems/ATM Networks other than Cirrus in which applicant participates in as a card issuer.
For Maestro licenses, list all EFT POS Systems other than Maestro in which applicant participates in as a card issuer
For affiliate applicants, provide sponsor(s) information and ICA for each brand:
MasterCard / MasterCard Electronic / MasterCard Cash / Maestro / Cirrus
ICA No.: / ICA No.: / ICA No.: / ICA No.: / ICA No.:
Full, legal name of sponsor
Street Address / Town/City / E-Mail
State/Country / ZIP/Postal Code
4—Date for Start of Activities
Indicate date card issuance and/or acquiring activity will commence.
Activity / MasterCard / MasterCard Electronic / MasterCard Cash / Maestro / Cirrus
Card Issuance
Acquiring Merchants / N/A
MasterCard ATM Network Acquiring / N/A
Cash Advances / N/A
5—Service Provider (MSP)
Does applicant plan to utilize the services provided by a Service provider? / Yes / No
If yes,before receiving program services from an MSP, the MSP must be registered by MasterCard Worldwide for such purpose. Applicants can contact for additional information.
6—Acquiring ATM/Cash Advance Outlets
Number of ATMs (on-line), Cash Advance Outlets, and Volume in US Dollars (cumulative)
Year 1 / Year 2 / Year 3
Number of ATMs (on-line)
Number of Cash Advance Outlets
Volume in US Dollars
7—Card Issuance
Number of Accounts and Volume in US Dollars (cumulative)
Business Plan—
Card Issuing Programs / Year 1 / Year 2 / Year 3
Number of Accounts / Volume in US Dollars / Number of Accounts / Volume in US Dollars / Number of Accounts / Volume in US Dollars
MasterCard
Domestic Use Only Domestic + Int’l Use
MasterCard Electronic
Domestic Use Only Domestic + Int’l Use
MasterCard Cash
Domestic Use Only Domestic + Int’l Use
Maestro
Domestic Use Only Domestic + Int’l Use
Cirrus
Domestic Use Only Domestic + Int’l Use
Total
For MasterCard issuing programs, will applicant offer: Credit Debit Both Prepaid
For MasterCard or Maestro issuing programs, what percent of portfolio will be prepaid: / %
Prepaid program type (e.g. gift, personal spend, etc.):
For prepaid programs, applicants can contact or additional information on completing the Special Issuer Registration form.
8—Merchant Acquiring
Number of Merchants and Volume in US Dollars (cumulative)
Business Plan - / MasterCard
Year 1 / Year 2 / Year 3
Merchant Categories / Number of Merchants / Volume in US Dollars / Number of Merchants / Volume in US Dollars / Number of Merchants / Volume in US Dollars
Retail
Airlines
Other Transportation (rail, bus, cruise, travel agency)
Mail/Telephone order
Internet Merchant (e-commerce)
Other High Risk Merchant*
Other
Total Volume (USD)
8—Merchant Acquiring (continued)
Business Plan - / MasterCard Electronic
Year 1 / Year 2 / Year 3
Merchant Categories / Number of Merchants / Volume in US Dollars / Number of Merchants / Volume in US Dollars / Number of Merchants / Volume in US Dollars
Retail
Airlines
Other Transportation (rail, bus, cruise, travel agency)
Mail/Telephone order
Internet Merchant (e-commerce)
Other High Risk Merchant*
Other
Total Volume (USD)
Business Plan - / MasterCard Cash
Year 1 / Year 2 / Year 3
Merchant Categories / Number of Merchants / Volume in US Dollars / Number of Merchants / Volume in US Dollars / Number of Merchants / Volume in US Dollars
Retail
Airlines
Other Transportation (rail, bus, cruise, travel agency)
Mail/Telephone order
Internet Merchant (e-commerce)
Other High Risk Merchant*
Other
Total Volume (USD)
Business Plan - / Maestro
Year 1 / Year 2 / Year 3
Merchant Categories / Number of Merchants / Volume in US Dollars / Number of Merchants / Volume in US Dollars / Number of Merchants / Volume in US Dollars
Retail
Airlines
Other Transportation (rail, bus, cruise, travel agency)
Mail/Telephone order
Internet Merchant (e-commerce)
Other High Risk Merchant*
Other
Total Volume (USD)
(*) Other high-risk categories include: Limousines/Car Services, Camera Sales, Dating & Escort Services, Massage Parlors, Computer Software/Hardware, Furniture Sales, Theatre/Ticket Agencies, Bail and Bond Payments, Membership Clubs (including Health), Employment Agencies, Time Share Sales, Casino Chips/Off-Track Betting/Bets/Lottery, and Adult Entertainment.
9—Applying Organization Must Read and Sign This Section
Applicant certifies that it has implemented an Anti-Money Laundering (AML) compliance program. The AML compliance program, as it pertains to MasterCard cards (including all cards with any MasterCard brand, e.g. Maestro, Cirrus), includes the following procedures:
- Thorough client identification
- Thorough client due diligence
- Record-keeping of such identification and due diligence
- Appropriate limitations on anonymous activities
- Client activity monitoring to detect suspicious activity
- Steps to be taken when suspicious activity is detected
- An audit process to test the controls
- All cardholders, merchant accounts and/or affiliates are checked against the specially designated nationals and blocked persons list issued by the U.S. Treasury's Office of Foreign Assets Control (OFAC)
in connection with its AML program. Applicant understands that in the event it fails to meet the requirements of the MasterCard AML program or in instances where an applicant is unable to adequately address identified risks to the satisfaction of MasterCard, MasterCard may reject the application.
By signing, applicant certifies the above is true and accurate:
(Signature of Officer) / (Typed Name and Title of Officer)
Applicant certifies that all information provided by applicant in the course of this application is accurate and complete in all respects. This application is solely used to determine if applicant meets eligibility requirements. Applicant understands that license(s) to use service marks or continued license(s) to use service marks may be conditioned upon the delivery of letters of credit or other similar arrangements pursuant to theMasterCard Rules. Applicant certifies that the undersigned is duly authorized to execute the application in the name of the applicant.
By: / Date:
Full, Legal Name of Applicant / (Month-Day-Year)
Authorized Signature
Typed Name and Title of above
10—Sponsor Certification
Those organizations that are being sponsored must also have their sponsoring licensee sign Section 11 which certifies the below is true and accurate.
This certifies the Institution noted below, as a sponsor for applicant, has reviewed the AML procedures of applicant, and that such AML procedures comply with applicable laws and regulations, as well as all MasterCard Standards (as such term is defined in the MasterCardRulesmanual). Institution has performed the following due diligence procedures related to applicant:
- Applicant, and all owners/directors/senior executives listed on the application are not listed on U.S. State Department list for sponsors of terrorism or the U.S. Treasury’s Office of Foreign Assets Control’s specially designated nationals and blocked persons list(http:
- Press and other public sources does not indicate money laundering risk issues
11—Sponsor Signatures
Organizations applying for affiliate licenses must also have their sponsoring Principal, Association,or Sponsoring TPP (U.S. Only) sign below:
Date
Full, Legal Name of Customer / (Month-Day-Year)
By: / Authorized Signature
Typed Name and Title of Signature above
12—RequiredDocuments for Applicants
The following documents must be provided with this form for all applicants:
Copy of the Regulatory Charter or the documents you have received from the applicable regulatory authority indicating your institution can engage in deposit-taking, loans or card business (e.g. banking license), as appropriate - For European applicants, the charter must be certified
Copy of the Certificate or Act of Incorporation (Legal document or act establishing the company) – For European applicants only
Confirmation from the applicable regulatory authority issued within the last 12 months confirming that your institution is regulated/supervised and financially fit to engage in card business - Not applicable for European applicants
Applicant’s Annual Report or audited financial statements issued within the past 18 months
License Agreements (For Europe applicants, 3 signed originals for affiliates and 2 originals for principals. For
all other regions 2 originals)Note: signature on License Agreement and Application must be the same.
Principal applicants must also provide the following (as applicable – contact your regional representative):
ICA/BIN Request Form (Form 658) – For MasterCard principal applications only
Billing Services Notification (Form 038) - Not applicable for European applicants
Summary Reports Request (Form 234)- Not applicable for European applicants
Submit original signed form and supporting documents to MasterCard Worldwide, Attn: Franchise Development, at the appropriate regional office address.
Region / Mailing Address
United States and Canada / 2000 Purchase Street
Purchase, NY 10577-2509
USA
Latin America/Caribbean / 801 Brickell Avenue, Suite 1200
Miami, FL 33131-4945
USA
Asia/Pacific / 152 Beach Road #35-00
The Gateway East
Singapore 189721
Europe / Chaussee de Tervuren 198A
Waterloo, Belgium B-1410
South Asia/Middle East Africa / Dubai Internet City
Building 4, 2nd Floor
Dubai, United Arab Emirates
If you have any questions regarding this application, you can contact Franchise Development Licensing at one of the appropriate Regional E-mail addresses listed below.
Region / Email Address
United States and Canada /
Latin America/Caribbean /
Asia/Pacific /
Europe /
South Asia/Middle East Africa /
NOTE: This application may be withdrawn if all required documentation is not provided within 90 days of receipt of original application by MasterCard or if Risk and Anti-Money Laundering requirements are not met. If applicant still wishes to pursue a license with MasterCard, a new application must be submitted.
631/Application / Page 1 of 11 / Revised: September 2012
©2012 MasterCard