POS REQUEST FORM Date
1. Complete every part of this form in BLOCK letters
2. Attach photocopies of relevant documents including certificate of company’s registration
COMPANY INFORMATION
Business Name
Merchant Trade Name
Type of Business: Sole Owner Partnership Limited Liability Company Public Limited Company
Others (Please specify)
SECTOR INFORMATION
Category of Merchant’s Business:
Store/Supermarket Restaurants Wholesale/Distributor Telecoms
Fuel Station Fast Food Hotel/Guest House Logistics (Courier)
Church/NGO Hospital Airlines Travel Agencies
Embassy Education/Schools Others (Please specify)
CONTACT INFORMATION
Office Address
LGA State
Name of Primary Contact Person
Designation Office Telephone
Mobile Phone Email Address
Name of Secondary Contact
Designation Office Telephone
Mobile Phone Email Address
POS OUTLET(S)
Deployment details of POS location(s) Number of POS terminal(s) required
Location of terminal Contact person Mobile phone
TRANSACTION CHARGES
Industry Local Card International Industry Local Card International
General Merchants 0.75% N/A Gaming 7.00% 10.00%
Wholesaler/Distributor 0.75% N/A Fast food/Restaurants 1.25% N/A
Fuel Station 0.00% N/A Hotel/Guest Houses 2.00 VISA/1.25% Others 5.50%
Schools/Hospital 1.25% 3.50% Others 0.75% N/A
POS NOTIFICATIONS
Daily Email notification of settlement Yes No
Email Address Mobile Number
POS Real Time transaction viewing (Monitoring Portal)
SETTLEMENT ACCOUNT DETAILS
Account name
Account Number
Branch
OTHER INFORMATION
Please provide any other relevant information in the space below:
I on behalf of ___________________________________________________________________ hereby certify that the
information provided in this form is true and accurate. I agree that ProvidusBank reserves the right to take appropriate
measure including legal actions if the information here is discovered to be false.
Local Card International MasterCard International Visa Card
Signature __________________ Designation ____________________________ Date _____________________
FOR OFFICIAL USE ONLY
To be completed by the Relationship Manager To be completed by ProvidusBank POS Officer
Merchant eligibility classification (Please tick one)
Merchant ID
Merchant Class “A” N350,000 ≥ N500,000
Merchant Class “B” N250,000 – N350,000
Merchant Class “C” N100,000 – N250,000 Terminal ID
Merchant Class “D” ≤N100,000
Relationship Manager Business Service Manager Terminal ID
Name______________________ Name______________________
Signature___________________ Signature___________________ Terminal ID
Telephone___________________ Telephone___________________
Terminal ID
Transactions to be supported on the POS terminal
Name of PTSP ___________________________
Cash Back Purchase Balance Enquiry Security/Information Zone _________________
Pin Change Transfer Mini Statement
Name and Signature _______________________
Bills Payment Cash Advance Airtime Vending
Date of Integration ________________________
Note: Your performance will be measured against your expected Monthly Transaction Value
