Russia Fast Food Specific Interchange Fee Application Form

  1. Preliminary remarks

Prior submitting any transaction under the Fast Foodspecific interchange fee conditions, each merchant/acquirer pair must fill in electronically the required information on this form;sign in the spaces provided and returnthe duly completed form to MasterCard Europe.

An official copy (not older than 3 months) of the merchant’s registration at the Ministry of Taxation of the Russian Federationshould be attached to the application form.

Only duly completed and signed submission will be reviewed by MasterCard Europe.

If eligibility criteria are met, MasterCard Europe will allocate a unique MasterCard Assigned ID. All acquired transactions claiming the specificinterchange will have to be identified in Clearing Message with both MasterCard Europe allocated MasterCard Assigned ID (in PDS 0176) and the merchant registered name (in DE 43 s1 ‘Card Acceptor Name’) as submitted in this form.

MasterCard reserves its right not to motivate a negative response to an application. At any time, a previously attributed MC Assigned ID to a merchant can be withdrawn at MasterCard’s sole discretion.

  1. Form category

Please select the appropriate box (only one box should be selected).

NewApplication(Select this box upon initial application)

New Acquirer(Select this box only for the notification of a new acquirer)

Modification of the merchant legal form or predominant activity(Select this box to indicatea modificationto the legal form or predominant activity of a merchant for which a MasterCard Assigned ID was previously allocated by MasterCard Europe)

  1. Pre-requisites (as of 1 September 2014)

As of 1 September 2014, please certify the following statement

I hereby certify that all POS terminals in the merchant’s stores are enabled for MasterCard contactless (PayPass)

  1. Applicant’s details

Requesting Licensee Details
Acquirer Name:OTKRITIE Bank Joint Stock Company
Acquiring ICA:11937
Address:13 bld., 11, Timura Frunze, Moscow, 119021, Russia
Contact Person:YURIY BOZHOR
Job Title: HEAD OF PLASTIC CARD DIV.
Tel:+7495 7558866 ext.113070 / Fax: +7495 7558866
e-mail:;
Date:
Signature:
Requesting Merchant Details
Merchant Name (+ Legal Form):
State Registration Number (ORGN):
Taxpayer Identification Number (INN):
MasterCard Assigned ID (not applicable for new application):
Head Office Address (Local Office if Head Office is outside Russia):
Contact Person:
Job Title:
Tel: / Fax:
e-mail:
Date:
Signature:
  1. Application request

Please describe the merchant performed activities, including the type of predominant activity
On-site рroduction & sale foods & non alcohol drinks for immediate consumption and for takeaway (carryout)
  1. Terminal Information

Number of stores / Number of POS terminals / Number of POS terminals enabled for MasterCard contactless (PayPass)