Open a Store WEBSTORE APPLICATION FORM Name APPLICANT INFORMATIONThe Original Bottle Cap Lure Company Opportunity Intake Form CONTACT INFORMATION Purchaser/Company Name * Your Name (Only fill if different from purchaser) Your Title/Position Billing Address Line 1 * Billing Address Line 2 City * Province/Territory * Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Postal Code * Phone Number * Email Address * WEBSTORE SETUP INFORMATION Desired Domain Name 1 * Desired Domain Name 2 Desired Domain Name 3 IMPORTANT: The cost of your desired domain may not exceed $15 CAD, if it does, you will be charged the difference Payment Gateway Provider * Square Moneris Your Logo The Bigger the Better (GIF, PNG, JPG, JPEG) Website Colours and/or Theme * Do you need additional pages? If Yes, how many? * One time customization fee $45.00 + GST per page Do you need additional email accounts? If Yes, how many? * $10/Month + GST per account BILLING INFORMATION The following information is needed to automatically charge your credit card. Cardholder Name (as shown on card) * Credit Card # * Credit Card Expiration * 3 Digit Security Code * Credit Card Type * MC VISA Authorization Charge * Monthly: $250 + GST Add-on Charges Social Media in a Box (est. $99) Credit Card's Postal Code (from credit card billing address) * Terms of Agreement By completing this application you authorize FCQNS.Tech Inc. to charge your credit card for the selected amount per billing cycle. You commit to paying a minimum of 6 months of service; if you terminate the service prior to 6 months, a charge of $15 per month for the remaining months will be charged. Registered website domain names and SSL certificates are renewed on an annual basis at no charge. However, if the cost for your website domain name exceeds $15 to purchase/renew, the difference will be charged to you. Monthly website tech support is available at no additional cost. Your selected authorization charge fee will remain in effect as long as the services are not in arrears. If services are interrupted due to non-payment, along with your renewal fee, there will an additional $75 reconnect fee. Payments are non-refundable. Agree By checking this off and submitting this application, you agree that all information filled above is correct and agree to all the industry rules and regulations of the products you will be selling.