Agent Registration

* Name :

Date :

If you have more than one location please indicate Total number :

Please indicate location addresses in theannexure

Company Name :

(Legal and doing business as name)

Description of Business :

Address :

City :

State :

Zip :

Federal Tax ID Number :

Phone Number :

* Email :

Do you currently offer money transfer service at any of your locations? : Yes No

If yes, please list out: :

THE ABOVE -REFERENCED COMPANY (THE "COMPANY") DESIRES TO ENTER INTO A BUSINESS RELATIONSHIP WITH ROYAL EXCHANGE USA INC. (ROYEX) HEREBY PROVIDES THE FOLLOWING INFORMATION FOR THE PURPOSE OF PRE-QUALIFYING TO OFFER ONE OR MORE OF ROYAL EXCHANGE USA INC. SERVICES. THE COMPANY UNDERSTANDS THAT THE ACCEPTANCE OF THIS INFORMATION BY ROYAL EXCHANGE USA INC. DOES NOT WARRANT OR OBLIGATE ROYAL EXCHANGE USA INC. INTO A BUSINESS WITH THE COMPANY.

OWNER 1		OWNER 2
Name :		Name :
Title (Owner, President Etc.) :		Title (Owner, President Etc.) :
Ownership % :		Ownership % :
Home Address :		Home Address :
City :		City :
State :		State :
Zip :		Zip :
E-mail Address :		E-mail Address :
Phone Number :		Phone Number :
Soc. Sec. No. :		Soc. Sec. No. :

Company hereby grants permission and authorization to Royal Exchange USA Inc. (ROYEX) and its affiliates, as well as trade references, Dun & Bradstreet, banks and consumer credit services and to state and Federal government agencies, without regard to whether they are listed herein, to verify, receive, exchange, and obtain business and/or personal credit and other information of company or any of its principals as part of this pre-qualification process or at anytime thereafter in connection with the ongoing application evaluation process by ROYEX. The Company further agrees that neither ROYEX nor anyone who has furnished REU information concerning Company or its principals shall be responsible for any losses or damages resulting from said verification, receipt, exchange, or obtaining business and/or personal credit information.

By submitting, I agree that all info entered was done accurately & truthfully.

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