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index.html
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<form action="form.html" method="POST">
<h1>KAPED One Application</h1>
<fieldset>
<legend>IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING A NEW ACCOUNT</legend>
To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. What this means for you: When you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents.
</fieldset>
<br>
</br>
<fieldset>
<legend>Owner 1</legend>
<label for="first name">First Name</label>
<input type="text" name="first-name" />
<label for="middle initial">Middle Initial</label>
<input type="text" name="middle initial" />
<label for="last name">Last Name</label>
<input type="text" name="last-name" />
<br/>
</br>
<label for="email address">Email</label>
<input type="text" name="email" placeholder="janedoe31@yahoo.com" />
<label for="telephone">Contact Number</label>
<input type="text" name="telephone" />
<br/>
</br>
<label for="home address">Home Address</label>
<input type="text" name="address" />
<label for="home address 2">Home Address 2</label>
<input type="text" name="address2" />
<label for="city">City</label>
<input type="text" name="city" />
<label for="state">State</label>
<input type="text" name="state" />
<label for="zip">Zip Code</label>
<input type="text" name="zip" />
<br/>
</br>
<label for="dob">Date of Birth</label>
<input type="text" name="dob" />
<label for="ssn">SSN</label>
<input type="text" name="ssn" />
</br>
</br>
<label for="dlnumber">Drivers License Number</label>
<input type="text" name="dlnumber" />
<label for="dlstate">Drivers License State</label>
<input type="text" name="dlstate" />
<label for="dldoi">Drivers License Date of Issuance</label>
<input type="date" name="dldoi" />
<label for="dlexp">Drivers License Exp.</label>
<input type="date" name="dlexp" />
</fieldset>
<fieldset>
<legend>Owner 2</legend>
<label for="first name2">First Name</label>
<input type="text" name="first-name2" />
<label for="middle initial2">Middle Initial</label>
<input type="text" name="middle initial2" />
<label for="last name2">Last Name</label>
<input type="text" name="last-name2" />
<br/>
</br>
<label for="email address2">Email</label>
<input type="text" name="email2" placeholder="janedoe31@yahoo.com" />
<label for="telephone2">Contact Number</label>
<input type="text" name="telephone2" />
<br/>
</br>
<label for="home address2">Home Address</label>
<input type="text" name="address2" />
<label for="home address 22">Home Address 2</label>
<input type="text" name="address22" />
<label for="city2">City</label>
<input type="text" name="city2" />
<label for="state2">State</label>
<input type="text" name="state2" />
<label for="zip2">Zip</label>
<input type="text" name="zip2" />
<br/>
</br>
<label for="dob2">Date of Birth</label>
<input type="date" name="dob2" />
<label for="ssn2">SSN</label>
<input type="text" name="ssn2" />
</br>
</br>
<label for="dlnumber2">Drivers License Number</label>
<input type="text" name="dlnumber2" />
<label for="dlstate2">Drivers License State</label>
<input type="text" name="dlstate2" />
<label for="dldoi2">Drivers License Date of Issuance</label>
<input type="date" name="dldoi2" />
<label for="dlexp2">Drivers License Exp.</label>
<input type="date" name="dlexp2" />
</fieldset>
<br>
</br>
<fieldset>
<legend>Business Information</legend>
<label for="company name">Company Name</label>
<input type="text" name="company name" />
<label for="ein">EIN</label>
<input type="number" name="ein" />
<label for="company location">Company Address</label>
<input type="text" name="company location" />
<br>
</br>
<label for="website">Website</label>
<input type="url" name="website" />
<label for="sic">SIC Code</label>
<input type="number" name="sic" />
<label for="start-date">Start Date</label>
<input type="date" name="start date" />
<legend>Ownership</legend>
<input name="ownership" list="ownership"/>
<datalist id="ownership"
<option value="Public">
<option value="Public">
<option value="Private">
</datalist>
<legend>Entity Type</legend>
<input name="entity" list="entity"/>
<datalist id="entity"
<option value="Public">
<option value="LLC">
<option value="Corporation">
<option value="Non Profit">
<option value="Sole Proprietor">
<option value="LLP">
<option value="Government">
</datalist>
<br>
<label for="occupation">Business Description</label>
<br>
<textarea name='business-description' name='description'></textarea>
</fieldset>
<br>
</br>
<fieldset>
<legend>Requested Services, Billing, and Payment Terms</legend>
Subject to the terms of the agreement, and acceptance by KAPED of your application, KAPED will arrange for establishment of an account using a virtual card web based solution that allows company to request single use card numbers. Please select the desired KAPED solution(s) below (all subject to availability and underwriting and final approval by KAPED)
<br>
<br>
PAYMENT: Company will remit all funds due to KAPED by debit ACH. "Debit ACH" means a debit initiated by KAPED against an account designated by company
</br>
</br>
<label for="loan amount">Requested Credit $</label>
<input type="number" name="loan amount" />
<legend>Terms:</legend>
<input type="radio" name="terms" value="secured">Secured Account
<br>
</br>
<legend>Requested Services</legend> <input type="checkbox" name="requested-services" value="credit-card">Secured Credit Card
<input type="checkbox" name="requested-services" value="kapital">Kapital
<input type="checkbox" name="requested-services" value="trak">Merchant Account
</fieldset>
<br>
</br>
<fieldset>
<legend>Bank Information (To be used for payments via ACH debit initiated by KAPED)</legend>
<label for="bank-name">Bank Name</label>
<input type="text" name="bank-name">
<br>
</br>
<label for="account-name">Name on Checking Account</label>
<input type="text" name="account-name">
<label for="routing-number">Routing Number</label>
<input type="number" name="routing">
<label for="bank-name">Bank Account Number</label>
<input type="number" name="account">
<br>
</br>
<label for="bank-contact-name">Contact Name</label>
<input type="text" name="bank-contact-name">
<label for="bank-contact-name">Phone Number</label>
<input type="number" name="bank-phone">
<input type="radio" name="length-of-time" value="15">15
<input type="radio" name="length-of-time" value="30">30
</fieldset>
<br>
</br>
<fieldset>
<html>
<style>
.body {
font-size: 17px;
margin: 0;
padding: 0;
}
.schumer-box {
font-size: 17px;
}
.schumer-apr {
font-size: 26px;
font-weight: bold;
}
.table {
border: 1px solid black;
width: 100%;
}
.th {
color: white;
}
.table-header-1 {
background-color: black;
}
.table-header-2 {
background-color: #3e3e3f;
}
.table-header-3 {
background-color: #a8a9ad;
}
.li {
margin-left: 15px;
}
.breakAl {
white-space: pre-wrap;
/* CSS3 */
white-space: -moz-pre-wrap;
/* Firefox */
white-space: -pre-wrap;
/* Opera <7 */
white-space: -o-pre-wrap;
/* Opera 7 */
word-wrap: break-word;
word-break: break-all;
}
</style>
</head>
<body>
<table class="schumer-box" border="1" cellpadding="5" cellspacing="0">
<tbody>
<tr>
<th class="table-header-1" colspan="2">INTEREST RATES AND INTEREST CHARGES</th>
</tr>
<tr>
<td>Annual Percentage Rate (APR) for Purchases</td>
<td><span class="schumer-apr">27.24%</span><sup>a</sup>
<ul>
<li>This APR will vary with the market based on the Prime Rate.</li>
<li>
</li>
</ul>
</td>
</tr>
<tr>
<td>How to Avoid Paying Interest on Purchases</td>
<td>Your due date will be a minimum of 25 days following the close of each billing
cycle. We will not charge interest on new purchases provided you have paid
your entire balance in full by the due date each month.</td>
</tr>
<tr>
<td>Minimum Interest Charge</td>
<td>If you are charged periodic interest, the charge will be no less than $1.00.</td>
</tr>
<tr>
<td>For Credit Card Tips from the
Consumer Financial Protection
Bureau</td>
<td>To learn more about factors to consider when applying for or using a credit
card, visit the website of the Consumer Financial Protection Bureau at
<a class="breakAl" href="http://www.consumerfinance.gov/learnmore" target="_blank">http://www.consumerfinance.gov/learnmore</a>.
</td>
</tr>
</tbody>
</table>
<br>
<table class="schumer-box" border="1" cellpadding="5" cellspacing="0">
<tbody>
<tr>
<th class="table-header-1" colspan="2">FEES</th>
</tr>
<tr>
<td width="150">Annual Fee</td>
<td>None</td>
</tr>
<tr>
<td>Penalty Fees<br><br>
Late Payment<br>
Returned Payment</td>
<td><br><br>
Up to <b>$38</b><br>
Up to <b>$38</b></td>
</tr>
</tbody>
</table>
<b>How We Will Calculate Your Balance:</b> How We Will Calculate Your Balance: We use the average daily balance method (including new transactions). See “Periodic Interest Charge
Calculation” section of this Agreement for more details.<br><br>
<b>Billing Rights:</b> Information on your rights to dispute transactions and how to exercise those rights are included in this Agreement. See "Your Billing Rights" section for full details.<br><br>
<b>Prime Rate:</b> Estimated variable APRs are based on the 5.50% Prime Rate.<br>
<b> a.</b> We add 21.74% to the Prime Rate to determine the Purchase APR (monthly periodic rate currently 2.27%).<br>
<p>The information about the costs of the credit card account described above is accurate as of January 1, 2019. This information may have changed. For the most current information contact us at 1-800-564-5740. </p><br>
<p><b>Authorization:</b> When you apply for a Kohl's credit card from Capital One, N.A. ("Capital One","we", or "us"), you agree to the following:<br>
1. You authorize us to obtain credit bureau reports in connection with your request for an account. If an account is opened, we may obtain credit bureau reports in connection with extensions of credit or the review or collection of your account. If you ask, we will tell you the name and address of each credit bureau from which we obtained a report about you.<br>
2. You are providing information in this application to Capital One and to Kohl’s. Capital One may provide information about you (even if your application is declined) to Kohl’s so that they can create and update their records, and provide you with services and special offers.<br>
3. By using the account or any card, or authorizing their use, you agree to the terms of the Cardmember Agreement. If you open your account in a Kohl’s store you acknowledge receipt of this disclosure and a copy of the Cardmember Agreement before your first purchase.<br>
4. As described in the Cardmember Agreement, we reserve the right to change the terms of your account (including the APRs) at any time, for any reason.<br>
5. We will review your credit history to determine if you qualify for an account and, if so, your credit line. Based on this review, you may not receive a card.<br>
6. You must be at least 18 years old to qualify (19 in AL and NE). <br>
7. You acknowledge that you must provide additional information electronically, including income. Alimony, child support or separate maintenance income need not be revealed if you do not wish it to be considered as a basis for repaying this obligation.<br>
8. You acknowledge that you have read and agree to be bound by the important rate and fee disclosures and the terms stated under this Authorization and the Cardmember Agreement section of the disclosures attached to this form. You agree that we may verify your information, check your credit history and secure follow-up credit reports on you.</p><br>
<p><b>Ohio Residents:</b> The Ohio laws against discrimination require that all creditors make credit equally available to all customers, and that credit reporting agencies maintain separate histories on each individual upon request. The Ohio Civil Rights Commission administers compliance with the law. </p><br>
<p><b>New York and Vermont Residents:</b> Capital One may obtain at any time your credit reports, for any legitimate purpose associated with the account or the application or request for an account, including but not limited to reviewing, modifying, renewing and collecting on your account. On your request, you will be informed if such a report was ordered. If so, you will be given the name and address of the consumer reporting agency furnishing the report. New York residents may contact the New York State Department of Financial Services to obtain a comparative listing of credit card rates, fees and grace periods.<br> New York State Department of Financial Services - 1-877-226-5697 or <span class="breakAl">http://www.dfs.ny.gov/consumer/creditdebt.htm</span></p><br>
<p><b>California Residents:</b><br>
Applicants: 1) may, after credit approval, use the credit card account up to its credit limit; 2) may be liable for amounts extended under the plan to any joint applicant. As required by law, you are hereby notified that a negative credit report reflecting on your credit record may be submitted to a credit reporting agency if you fail to fulfill the terms of your credit obligations.</p><br>
<p><b>Notice to Married Wisconsin Residents:</b> No provision of any marital property agreement, unilateral statement or court decree adversely affects our rights, unless you give us a copy of such agreement, statement or court order before we grant you credit, or we have actual knowledge of the adverse obligation. All obligations on this account will be incurred in the interest of your marriage or family. You understand that we may be required to give notice of this account to your spouse.</p><br>
<p><b>Married Wisconsin residents must furnish their (the applicant's) name and social security number as well as the name and address of their spouse to Kohl's, PO Box 3120, Milwaukee, WI 53201.</b> </p><br>
<p>Omission of any information requested on the application may be reason for denial of an account.</p><br>
<p><b>IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING A NEW ACCOUNT:</b></p><br>
<p>To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account.</p> <br>
<p><b>What this means for you:</b> when you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents. </p>
<p>01/19</p>
</body>
</html>
</fieldset>
<fieldset>
<legend>Personal Guarantee</legend>
In exchange for KAPED'S and its sponsoring bank's (the "Guaranteed Parties") acceptance of the Agreement, the undersigned unconditionally and irrevocably guarantees the full payment and performance of Customer's obligations under the foregoing Agreement as modified from time to time, whether before or after termination or expiration of the Agreement and whether or not the undersigned has received notice of any amendment of such Agreement. The undersigned waives notice of default by Customer and agrees to indemnify the Guaranteed Parties for any and all amounts due from Customer under the Agreement. The Guaranteed Parties shall not be required to first proceed against Customer to enforce any remedy before proceeding against the undersigned. This is a continuing personal guaranty and shall not be discharged or affected for any reason. The undersigned understands that this is a personal guaranty of payment and not of collection and that the Guaranteed Parties are relying upon this Personal Guaranty in entering into the foregoing Agreement.
<br>
</br>
<label for="guarantor-name">Name</label>
<input type="text" name="guarantor" />
<br>
</br>
<label for="title">Title</label>
<input type="text" name="title" />
<br>
</br>
<label for="date-signed">Date</label>
<input type="date" name="date-signed" />
<input type="checkbox" name="accept" value="i-understand-and-accept-personal-liability"> I understand & accept personal liability
</fieldset>
<fieldset>
<legend>Comments</legend>
<textarea name='business-description' name='description'></textarea>
<div id="signature-pad" class="m-signature-pad">
<div class="m-signature-pad--body">
<section class="signature-component">
<h1>Draw Signature</h1>
<h2>with mouse or touch</h2>
<canvas id="signature-pad" width="400" height="200"></canvas>
</section>
<input type='hidden' name='articleid' id='articleid' value='<? echo $_GET["id"]; ?>' />
</fieldset>
<button type="submit">Submit</button>
</form>