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Online Merchant Form

Your business
Trading name
What is you ABN?
Contact person/position within the business
Contact phone
Fax
Business email
Does your business have a website?
Website URL
Enter the URL of your business website.
Business address
Would you like to be added to the gem Visa store locator?
Your industry
What is your industry?
Healthcare Practice
What is your core business?
Please specify your core business
Are you registered for GST?
Are you registered with the relevant licencing authority to carry on your current business?
Do you have a practice or clinic?
I understand that I will need to provide financial statements if in practice less than 2 years.
I understand that there is an accreditation fee of $548.90 ($499 + $49.90 GST).
I understand that if my account remains inactive for a period of 12 months or more it will be closed.
Healthcare requirements
<p>Please acknowledge your understanding that we'll require the following documents from you:</p>
Professional Indemnity Insurance
Board Registration for Practice/Practitioners
Current Photo ID of signatories
Financials if practice trading for less than 2 years under current ownership
Retailer
What is your core business product?
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Please specify your core business?
Are you a part of a National Retail Group?
Which group?
What % of your sales are made in a physical store?
What % of your sales are made online?
What % of your sales are made over the phone?
What % of your sales are made by a sales person in a customer's home?
Total
Has your business been trading for a minimum of 12 months?
Are you registered for GST?
Are you a director of the business applying for accreditation?
Does your annual turnover exceed 2 million dollars?
Does your annual turnover exceed 10 million dollars?
Do you have a retail shopfront?
I understand that I will need to provide financial statements.
I understand that there is an accreditation fee of $548.90 ($499 + $49.90 GST)
I understand that if my account remains inactive for a period of 12 months or more it will be closed.
How did you hear about becoming a partner?
Are you currently offering finance through another provider?
Do you currently use any other services provided by us?
Please rate your satisfaction with completing this form
Privacy acknowledgement
I have read and agree to the <a href="https://www.latitudefinancial.com.au/privacy/" target="_blank">Privacy Policy</a>.
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