Merchant Application Package

Transcription

1 Merchant Application Package Please include: Merchant Processing Application and Agreement Acquirer Confirmation Page W-9 Request for Taxpayer ID Equipment and Software Checklist Equipment Loan Form for Any Loaned Equipment Copy of Drivers License Copy of Voided Check or Bank Letter

2 MERCHANT PROCESSING APPLICATION PLEASE PRINT LEGIBLY AND FILL OUT COMPLETELY Representative Name Rep# Sales Office # Phone # Merchant's Legal Business Name: (for Sole Proprietorships, enter Principal's name) Doing Business As Name: GENERAL INFORMATION Federal Tax ID Number (TIN) / Employer Identification Number (EIN): Social Security Number (SSN): (for Sole Proprietorships only) Important Notice: Failure to provide accurate Legal Business Name, TIN, EIN and/or SSN may result in a withholding of merchant funding per IRS regulations. See Part V A.4 of the Merchant Services Program Guide for further information. Business Address: (no P.O. Boxes) City/State/Zip: Time at Location: / / Mailing Address: City/State/Zip: / / Business Phone: Customer Service Phone: Cell Phone: Business Fax: Contact Name: (First) (Last) # of Locations: Time in Business: Business Business Website: Yes (provide website address below) No Website BUSINESS INFORMATION PROCESSING HISTORY PRINCIPAL 1 PRINCIPAL 2 PRINCIPAL 3 PRINCIPAL 4 Retail Swiped % Merchant Type: Retail Keyed % Retail Restaurant Convenience Petroleum Pay Clerk Internet % Retail w/ Tip Lodging Public Sector Mail/Phone Fast Food Cash Advance/Banks Only Mail Order % Internet Utility Petroleum Pay at Pump TOTAL % 100 Business to Business: B-2-B % B-2-C % Method of Marketing: (attach examples) Mail, Telephone or Internet Sales: Newspaper Magazine/Catalog Who performs product/service fulfillment? Direct Mail Internet Merchant Vendor/Fulfillment House TV/Radio Outbound Telemarketing Vendor/Fulfillment House Information: Specific Type of Product(s)/Service(s) Sold: Name: Address: Phone: Seasonal Merchant Months Merchant will process: Customer Return Policy: Refund w/in 30 days Exchange Only None Has Applicant ever accepted credit cards before? Yes No If Yes, who was your processor? Former Merchant Number(s): Type of Ownership: Sole Prop. Non-Profit Gov t. Corp. Legal/Medical Trust Estate LLC Corp. Assoc. Partnership Tax Exempt Business Location: Store Front Office Home Does Merchant use third party to store, process or transmit cardholder data? Yes No Third Party Information: Name: Address: Phone: Software Used by Third Party: Number of Days Until Product/Service is Delivered: MasterCard /Visa /American Express /Discover sales transactions are settled: Date of Order Date of Shipment Has Applicant ever had a previous credit card processor terminate its merchant account? Yes No If Yes, by whom? Explanation for prior closure (attach additional pages if necessary): PRINCIPAL / BENEFICIAL OWNERS How Long at This Address? Home Phone: Date of Birth: Principal 1 How Long at This Address? Home Phone: Date of Birth: Principal 2 How Long at This Address? Home Phone: Date of Birth: Principal 1 How Long at This Address? Home Phone: Date of Birth: Principal 2 i3 Verticals, LLC is a registered ISO of Deutsche Bank AG, New York, NY Page 1 of 3

3 PRINCIPAL 5 How Long at This Address? Home Phone: Date of Birth: Principal 2 Comments: MCC/SIC: Application Fee: $ VISA / MC / DSC Auth: $ per item Discount Collected: Daily Monthly SCHEDULE OF FEES / PROCESSING LIMITS (TO BE COMPLETED BY SALES REPRESENTATIVE) Early Termination Fee: $ Annual Bankcard Sales: $ Merchant Service Fee: American Express Auth: $ per item Average Ticket: $ $ per month ACH Reject Fee: $ EBT Fee: High Ticket: $ $ per item Retrieval Fee: $ Monthly Minimum VISA / MC / Discover: WEX / Voyager Transaction Fee: Discount Fee $ Chargeback Fee: $ Interchange plus % $ per transaction plus Dues and Assessments Interchange Clearing Fee: % Offline-Debit Discount Rates: AVS: $ per inquiry Regulatory Product Fee: $ Qualified (Qual) Fee: % American Express: Batch Header: $ per batch Mid-Qualified Fee: Qual plus % Pass-Through Pricing plus % Invalid TIN Fee: $ Voice Auth: $ each Non-Qualified Fee: Qual plus % PCI Non-Compliance Fee: $ Return Trans Fee: PIN Debit Card Fees: $ Settled Transaction Fee: $ PCI Compliance Monthly Fee: $ Access Fee: $ per month Credit Card Discount Rates: Network Fees plus % TransArmor Fee $ per inquiry PCI Compliance Annual Fee: $ Qualified (Qual) Fee: % Transaction Fee: $ Mid-Qualified Fee: Qual plus Other Volume % Rate: Inactivity Fee: $ % Other Item Fee: $ Non-Qualified Fee: Qual plus % VISA / MC / Discover: Annual Fee: $ Settled Transaction Fee: $ Enhanced Recovery Reduced Rate: % Wireless Fees Payment Gateway Fees Offine-Debit and Credit Card Discount (per Wireless set-up) (per Gateway set-up) Offine-Debit Qualified Fee: % Rates disclosed apply to VISA, Quantity Quantity MasterCard and Discover transactions. Credit Card Qualified Fee: % Set-up Fee: $ x Set-up Fee: $ x American Express: Monthly Access: American Express Discount Rates: $ Enhanced Recovery x Monthly Access: $ x Reduced Rate: % Qualified (Qual) Fee: % Per Auth Fee: $ Per Auth Fee: $ Credit Card Qualified Fee: % Mid-Qualified Fee: % Applies to Non-qualified VISA, MasterCard, Non-Qualified Fee: % Discover, and American Express Offine- If applicable, we may also charge fees to Merchant for the specific circumstances as Settled Transaction Fee: $ Debit and/or Credit Card Transactions; see described in Section 25 of the Program Guide. See Section 25 of the Program Guide Paragraph 25.1 of the Merchant Services for other charges that may apply. Program Guide. The following fees will be passed through to merchant if applicable: VISA ACQ ISA, APF, Misuse of Auth, NPF/FANF (refer to Network Fee Billing Tables in Merchant Services Program Guide), Zero Floor Limit, Transaction Integrity Fee, Int l Acquiring, Kilobyte, and AFD Partial Auth Non-Participant Fees; MasterCard Acquirer Support, Cross Border, Reversal Integrity, NABU, License, Kilobyte, CVC2, and ICA AVS Fees; Discover Data Usage, Int l Processing, Service, and Network Auth Fees; American Express Network Auth Fee; and PIN Debit Network Annual Fees. ADDED SERVICE ENROLLMENT Debit Card Services Electronic Benefits Transfer (EBT) EBT/FNS#: WEX / Voyager Check Services Gift Card Services Lease Services CARD ACCEPTANCE Accept all MasterCard, Visa, Discover, and American Express Transactions (presumed, unless any selections below are checked) MasterCard Acceptance: MC Credit transactions MC Non-PIN Debit transactions Visa Acceptance: Visa Credit transactions Visa Non-PIN Debit transactions Discover Acceptance: Discover Credit Transactions Discover Non-PIN Debit transactions See Paragraph 1.9 of the Merchant Services Program Guide for details regarding limited acceptance. AMERICAN EXPRESS CARD ACCEPTANCE Existing American Express Direct SE Merchant Number (if applicable): BANKING INFO American Express Acceptance: American Express Credit transactions ***IMPORTANT - COMPLETE THE FOLLOWING SECTION AND INCLUDE A VOIDED BUSINESS CHECK FROM ACCOUNT*** Bank Name: Bank Address: City: State: Zip: Branch: Bank Phone: Contact Name: Transit # (ABA Routing): Account # (DDA): MERCHANT SITE SURVEY Date: Type of Building: Square Footage (approximate): Inspector s Comments: I have verified the identification of the above listed principal(s): Under the penalty of perjury and accountability, I hereby certify I personally conducted this premises inspection described above and hereby certify that this business is legitimate. Sales Representative Signature: Inspector s Signature: i3 Verticals, LLC is a registered ISO of Deutsche Bank AG, New York, NY Page 2 of 3

4 I31804(ia) SIGNATURES I31804(ia) Client certifies that all information set forth in this completed Merchant Processing Application is true and correct and that Client has received a copy of the Program Guide [Version I31904(ia)] and Confirmation Page, which is part of this Merchant Processing Application (consisting of Sections 1-9), and by this reference incorporated herein. Client acknowledges and agrees that we, our Affiliates and our third party subcontractors and/or agents may use automatic telephone dialing systems to contact Client at the telephone number(s) Client has provided in this Merchant Processing Application and/or may leave a detailed voice message in the event that Client is unable to be reached, even if the number provided is a cellular or wireless number or if Client has previously registered on a Do Not Call list or requested not to be contacted Client for solicitation purposes. Client hereby consents to receiving commercial electronic mail messages from us, our Affiliates and our third-party subcontractors and/or agents from time to time. Client further agrees that Client will not accept more than 20% of its card transactions via mail, telephone or Internet order. However, if your Application is approved based upon contrary information stated in Section 5, Transaction Information section above, you are authorized to accept transactions in accordance with the percentages indicated in that section. By signing below, each of the undersigned authorizes us, our Affiliates and our third-party subcontractors and/or agents to verify the information contained in this Application and to request and obtain from any consumer reporting agency and other sources, including bank references, personal and business consumer reports and other information and to disclose such information amongst each other for any purpose permitted by law. If the Application is approved, each of the undersigned also authorizes us, our Affiliates and our third-party subcontractors and/or agents to obtain subsequent consumer reports and other information from other sources, including bank references, in connection with the review, maintenance, updating, renewal or extension of the Agreement or for any other purpose permitted by law and disclose such information amongst each other. Each of the undersigned furthermore agrees that all references, including banks and consumer reporting agencies, may release any and all personal and business credit financial information to us, our Affiliates and our third-party subcontractors and/or agents. Each of the undersigned authorizes us, our Affiliates and our third-party subcontractors and/or agents to provide amongst each other the information contained in this Merchant Processing Application and Agreement and any information received subsequent thereto from all references, including banks and consumer reporting agencies for any purpose permitted by law. It is our policy to obtain certain information in order to verify your identity while processing your account application. As part of our approval, processing services, continuing fraud prevention and account review processes, the undersigned consents to the use of information gathered online or that you submit to us, and/or automated electronic computer security screening, by us or our third-party vendors. By signing below, I represent that I have read and am authorized to sign and submit this application for the above entity which agrees to be bound by the American Express Card Acceptance Agreement ( Agreement ), and that all information provided herein is true, complete and accurate. I authorize i3 Verticals, LLC and American Express Travel Related Services Company, Inc. ( AXP ) and AXP s agents and Affiliates to verify the information in this application and receive and exchange information about me personally, including by requesting reports from consumer reporting agencies from time to time, and disclose such information to their agent, subcontractors, Affiliates and other parties for any purpose permitted by law. I authorize and direct i3 Verticals, LLC and AXP and AXP agents and Affiliates to inform me directly, or inform the entity above, about the contents of reports about me that they have requested from consumer reporting agencies. Such information will include the name and address of the agency furnishing the report. I also authorize AXP to use the reports from consumer reporting agencies for marketing and administrative purposes. I am able to read and understand the English language. Please read the American Express Privacy Statement at to learn more about how AXPs protects your privacy and how AXP uses your information. I understand that I may opt out of marketing communications by visiting this website or contacting American Express at 1-(800) I understand that upon AXP s approval of the Application, as applicable, the entity will be provided with the Agreement and materials welcoming it to AXP s Card acceptance program. Client authorizes i3 Verticals, LLC and Bank and their affiliates to debit Client s designated bank account via Automated Clearing House (ACH) for costs associated with equipment hardware, software and shipping. You further acknowledge and agree that you will not use your merchant account and/or the Services for illegal transactions, for example, those prohibited by the Unlawful Internet Gambling Enforcement Act, 31 U.S.C. Section 5361 et seq, as may be amended from time to time, or processing and acceptance of transactions in certain jurisdictions pursuant to 31 CFR Part 500 et seq. and other laws enforced by the Office of Foreign Assets Control (OFAC). Client certifies, under penalties of perjury, that the federal taxpayer identification number and corresponding filing name, and all beneficial ownership information provided herein are complete and correct. Client agrees to all the terms of this Merchant Processing Application and Agreement. This Merchant Processing Application and Agreement shall not take effect until Client has been approved and this Agreement has been accepted by i3 Verticals, LLC and Bank. Client s Business Principal/Officer: Signature X Title Signature X Print Name of Signer Date Print Name of Signer Signature X Title Title Date Print Name of Signer Date Personal Guarantee: In exchange for i3 Verticals, LLC and Deutsche Bank AG (the Guaranteed Parties) acceptance of the Agreement, the undersigned unconditionally and irrevocably guarantees the full payment and performance of Client s obligations under the foregoing agreements, as applicable, as they now exist or as modified from time to time, whether before or after termination or expiration of such agreements and whether or not the undersigned has received notice of any amendment of such agreements. The undersigned waives notice of default by Client and agrees to indemnify the Guaranteed Parties for any and all amounts due from Client under the foregoing agreements. The Guaranteed Parties shall not be required to first proceed against Client 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 agreements, as applicable. Personal Guarantee Signature X Print Name: Date Personal Guarantee Signature X Print Name: Date Accepted By i3 Verticals, LLC Deutsche Bank AG, 60 Wall Street, New York, NY Signature X Signature X Title Date Title Date i3 Verticals, LLC is a registered ISO of Deutsche Bank AG, New York, NY Page 3 of 3

5 I3V1904(ia) CONFIRM ATION PAGE PROCESSOR Name: I3 Verticals, LLC INFORMATION: Address: 2500 Cumberland Parkway, Atlanta, GA URL: Customer Service #: Please read the Program Guide in its entirety. It describes the terms under which we will provide merchant processing Services to you. From time to time you may have questions regarding the contents of your Agreement with Bank and/or Processor. The following information summarizes portions of your Agreement in order to assist you in answering some of the questions we are most commonly asked. 1. Your Discount Rates are assessed on transactions that qualify for certain reduced interchange rates imposed by MasterCard, Visa, Discover and PayPal. Any transactions that fail to qualify for these reduced rates will be charged an additional fee (see Section 25 of the Program Guide). 2. We may debit your bank account (also referred to as your Settlement Account) from time to time for amounts owed to us under the Agreement. 3. There are many reasons why a Chargeback may occur. When they occur, we will debit your settlement funds or Settlement Account. For a more detailed discussion regarding Chargebacks see Section 14 of the Your Payments Acceptance Guide. 4. If you dispute any charge or funding, you must notify us within 60 days of the date of the statement where the charge or funding appears for Card Processing. 5. The Agreement limits our liability to you. For a detailed description of the limitation of liability see Section 27, 37.3, and of the Card General Terms. 6. We have assumed certain risks by agreeing to provide you with Card processing or check services. Accordingly, we may take certain actions to mitigate our risk, including termination of the Agreement, and/or hold monies otherwise payable to you (see Card Processing General Terms in Section 30, Term; Events of Default and Section 31, Reserve Account; Security Interest), under certain circumstances. 7. By executing this Agreement with us you are authorizing us and our Affiliates to obtain financial and credit information regarding your business and the signers and guarantors of the Agreement until all your obligations to us and our Affiliates are satisfied. 8. The Agreement contains a provision that in the event you terminate the Agreement prior to the expiration of your initial four (4) year term, you will be responsible for the payment of an early termination fee as set forth in Part IV, A.3 under Additional Fee Information. 9. If you lease equipment from Processor, it is important that you review Section 1 in Third Party Agreements. Bank is not a party to this Agreement. THIS IS A NON-CANCELABLE LEASE FOR THE FULL TERM INDICATED. 10. Card Organization Disclosure Visa and MasterCard Member Bank Information: Deutsche Bank,AG The Bank s mailing address is 60 Wall Street, New York, NY Important Member Bank Responsibilities: Important Merchant Responsibilities: a) The Bank is the only entity approved to extend acceptance of Visa a) Ensure compliance with Cardholder data security and storage requirements. and MasterCard products directly to a merchant. b) Maintain fraud and Chargebacks below Card Organization thresholds. b) The Bank must be a principal (signer) to the Agreement. c) Review and understand the terms of the Merchant Agreement. c) The Bank is responsible for educating merchants on pertinent Visa d) Comply with Card Organization Rules and applicable law and regulations. and MasterCard rules with which merchants must comply; but this information may be provided to you by Processor. d) The Bank is responsible for and must provide settlement funds to the merchant. e) The Bank is responsible for all funds held in reserve that are derived from settlement. f) The Bank is the ultimate authority should a merchant have any problems with Visa or MasterCard products (however, Processor also will assist you with any such problems). e) Retain a signed copy of this Disclosure Page. f) You may download Visa Regulations from Visa s website at: g) You may download MasterCard Regulations from MasterCard s website at: h) You may download American Express Merchant Operating Guide from American Express website at: Print Client s Business Legal Name: By its signature below, Client acknowledges that it has received the Merchant Processing Application, Program Terms and Conditions [version I3V1904(ia)] consisting of 45 pages [including this Confirmation Page and the applicable Third-Party Agreement(s)]. Client further acknowledges reading and agreeing to all terms in the Program Terms and Conditions. Upon receipt of a signed facsimile or original of this Confirmation Page by us, Client s Application will be processed. NO ALTERATIONS OR STRIKE-OUTS TO THE PROGRAM TERMS AND CONDITIONS WILL BE ACCEPTED. Client s Business Principal: Signature (Please sign below): X Title Date Please Print Name of Signer I3V1904(ia)

6 Form W-9 (Rev. December 2014) Department of the Treasury Internal Revenue Service Request for Taxpayer Identification Number and Certification 1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank. Give Form to the requester. Do not send to the IRS. Print or type See Specific Instructions on page 2. 2 Business name/disregarded entity name, if different from above 3 Check appropriate box for federal tax classification; check only one of the following seven boxes: 4 Exemptions (codes apply only to certain entities, not individuals; see Individual/sole proprietor or C Corporation S Corporation Partnership Trust/estate instructions on page 3): single-member LLC Exempt payee code (if any) Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) Exemption from FATCA reporting Note. For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for the tax classification of the single-member owner. code (if any) Other (see instructions) a (Applies to accounts maintained outside the U.S.) 5 Address (number, street, and apt. or suite no.) Requester s name and address (optional) 6 City, state, and ZIP code 7 List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for guidelines on whose number to enter. Social security number or Part II Certification Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. I am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 3. Sign Here Signature of U.S. person a General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. Information about developments affecting Form W-9 (such as legislation enacted after we release it) is at Purpose of Form An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following: Form 1099-INT (interest earned or paid) Form 1099-DIV (dividends, including those from stocks or mutual funds) Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) Form 1099-S (proceeds from real estate transactions) Form 1099-K (merchant card and third-party network transactions) Date a Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition) Form 1099-C (canceled debt) Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding? on page 2. By signing the filled-out form, you: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected income, and 4. Certify that FATCA code(s) entered on this form (if any) indicating that you are exempt from the FATCA reporting, is correct. See What is FATCA reporting? on page 2 for further information. Cat. No X Form W-9 (Rev )