Form 5
SPOC Nomination
Registered Business Name: Trade Name: (If applicable)
CONTACT INFORMATION
Note: Please attach an additional sheet in case there are more addresses to be nominated
Primary Contact Details
Name:
Designation:
Email Address:
Tick this box if same as Primary Contact details Tick this box if same as Primary Contact details
For Pre-Funding For Billing and Collection
Name: Name:
Designation: Designation:
Email Address: Email Address:
Tick this box if same as Primary Contact details Tick this box if same as Primary Contact details
For Transaction History Reports For Partner Support Concerns
Name: Name:
Designation: Designation:
Email Address: Email Address:
Tick this box if same as Primary Contact details Tick this box if same as Primary Contact details
For Brand Reports For Settlement Report Emails
Name: Name:
Designation: Designation:
Email Address: Email Address:
Tick this box if same as Primary Contact details Tick this box if same as Primary Contact details
For LMS Nomination Others: ________________________
Name: Name:
Designation: Designation:
Email Address: Email Address:
Tick this box if same as Primary Contact details Tick this box if same as Primary Contact details
Others: ________________________ Others: ________________________
Name: Name:
Designation: Designation:
Email Address: Email Address:
PARTNER DECLARATION
The Partner authorizes GXI to verify and investigate any information contained herein through what-
ever means and/or sources it may consider appropriate. The Partner understands and agrees that
falsifying or misrepresenting any information provided in this application or supporting documents
constitutes grounds for legal action, and/or the rejection or termination of the Partner’s application,
and/or suspension of the Partner’s wallet. The Partner shall immediately notify GXI in writing of any
change to any of the information provided in this form.
By submitting this application, the Partner certifies that it understands and agrees to comply with the
terms set forth herein.
Signature over Printed Name of Business Designation: Date:
Owner/s or Authorized Representative/s:
ACCOUNT MANAGER DECLARATION
The Account Manager certifies to having checked and verified the supporting application requirements against the
original documents and found them to be authentic and in accordance with G-Xchange, Inc.'s (GXI) requirements.
Furthermore, the Account Manager acknowledges and understands that any inaccuracies, discrepancies, or falsifi-
cations in the provided information may subject the Account Manager to certain sanction or penalties, including
disciplinary sanctions in accordance with GXI's Code of Conduct for Employees.
By signing this declaration, the Account Manager acknowledges and understands that any failure to maintain these
standards may compromise the trust and operational integrity of GXI, and confirms and accepts accountability for
any errors or omissions that may arise from the submitted documentation, with such accountability extending to the
accuracy of the information at the time it is provided and to any subsequent changes or updates to such informa-
tion.
Printed Name over Signature of Account Manager: Date:
