MERCHANT APPLICATION Merchant # New Location

Transcription

1 Business Information Legal Name (as it appears on your income tax return): MERCHANT APPLICATION Merchant # New Location Note: Failure to provide accurate information may result in a withholding of merchant funding per IRS regulations. (See Terms and Conditions for further information) Additional Location 4100 W. Royal Ln. Suite 150 Irving, TX Tel: Fax: FD ISO#: SignaPay1712(ia) Name of Account (Doing Business As): Legal Address: Physical Street Address (No P.O. Box): City: State: Zip: City: State: Zip: Phone # Address: Contact: DBA Phone#: Website Address: www. Fax#: Must Choose One Mailing Address: Retrievals & chargebacks DBA Address Legal Address Statements DBA Address Legal Address Federal Tax # (as it appears on your income tax return): I certify that I am a foreign entity/nonresident alien. (If checked, please attach IRS Form W-8) # of Locations: Years in Business: Years Owned Business: Place of Legal Formation: Bank Reference: Contact: Phone #: Country of Primary Business Operations: Name as it Appears on your Tax Return: NOTE: Failure to provide accurate information may result in a withholding of merchant funding per IRS regulations. (See Part III, Section A.4 of your Program Guide for further information) Owners or Officers Individual Ownership Must be Equal to or Greater than 50% Name: : of Birth: Applicant s SS #: Residence Address: City: State: Zip: % Equity Ownership: # Years: US Government Issued ID#: Name: Residence Address: Type of ID: : City: Expiration : Country of Citizenship (if not US): Home Phone: of Birth: Applicant s SS #: % Equity Ownership: State: Zip: # Years: US Government Issued ID#: Type of ID: Expiration : 3. Business Profile Type of Ownership: Sole Proprietor Assoc/Estates/Trusts Joint Venture Government Corporation (Privately Traded) Corporation (Publicly Traded) Medical or Legal Corp Partnership Tax Exempt Org Single Member LLC Multi Member LLC Civic Assoc Limited Partnership Political Org Other: Type of Goods or Services Sold *SIC/MCC: IATA/ARC: (MCC 4722 Only) NOTE:*If your business is classified as High Risk and assigned (or is later assigned based upon your business activity) any of the following Merchant Category Codes (MCC): 5966, 5967 and , then registration is required with Visa and/or MasterCard within 30 days from when your account becomes active. An Annual registration Fee of $500 may apply for Visa and/or MasterCard (total registration fees could be $1,000.00). Failure to register could result in fines in excess of $10, for violating Visa and/or MasterCard Regulations 2. 1 Registration for MCC 7841 is only required for non-face-to-face adult content. 2 Information herein, including applicable MCCs, is subject to change. Do you currently accept Discover /Visa/MasterCard/American Express? Name of Current Processor: Name of Previous Processor: Yes No Reason for Leaving: (If yes, you should submit 3 current months statements.) Rate Service Terminated Other: Has Merchant or any associated principal disclosed below file bankruptcy or been subject to involuntary bankruptcy? Yes No : Do you use any third party to store, process or transmit cardholder data? Yes No If Yes, give name/address: 4. Business Trade Suppliers List Two Name: Address: Contact: Phone #: Name: Address: Contact: Phone #: 5. Merchant Site Survey Report To Be Completed by Sales Representative Country of Citizenship (if not US): Sales Profile Merchant Type: Retail Restaurant Lodging Service Internet Home Based Other Home Phone: Discover/Visa/MasterCard/American Express Sales Profile (Be Accurate): Card Swipe % Manual Key Entry with Imprint, Card Present % Mail Order/Telephone % Internet % Total = 100% Seasonal? No Yes High Volume Months Open: Merchant Location: Retail Location with Store Front Office Building Internet Residence Other Area Zoned: Commercial Industrial Residential Square Footage: ,000 2,001+ Further Comments by Inspector (Must Complete) I hereby verify that this application has been fully completed by merchant applicant and that I have physically inspected the business premises of the merchant at this address and the information stated above is true and correct to the best of my knowledge and belief. Verified and Inspected by: Office #: Representative #: Representative : : X X. Revised SignaPay is a registered ISO of Merrick Bank, South Jordan UT, Wells Fargo Bank, N.A., Walnut Creek, CA, Esquire Bank, Garden City, NY. Page 1 of 3

2 6. Discover / Visa / Mastercard / AMEX Standard Retail/High Risk Retail Rates Merchant Chooses to accept the following: Tiered ERR Interchange + Pricing DISC/VS/MC/AMEX (Other Cards) Discount Rate: % DISC/VS/MC/AMEX - Mid-Qual: % DISC/VS/MC/AMEX - Non-Qual: % Mail / Phone / Internet / Touchtone Rates Merchant Chooses to accept the following: Tiered ERR Interchange + Pricing DISC/VS/MC/AMEX (Other Cards) Discount Rate: % DISC/VS/MC/AMEX - Mid-Qual: % DISC/VS/MC/AMEX - Non-Qual: % Accept all MasterCard, Visa, Discover Network and American Express Transactions (presumed, unless any selections below are checked) MasterCard MC Credit Transactions VS Credit Transactions DISC Credit Transactions MC Non-PIN Debit Trans. VS Non-PIN Debit Trans. DISC Non-PIN Debit Trans. Discount Collected Ach Detail Daily Individual Visa Discover Network American Express Combined See Section 9 of the Program Guide for details regarding limited acceptance. American Express Credit Transactions 7. Fees DISC/VS/MC/AMEX Transaction Fee: Non-Bankcard Transaction Fee: Sales Transaction Fee: Return Transaction Fee: Statement Fee: Minimum: Electronic AVS EBT Transaction Fee: EBT Statement Fee: Batch Fee: Per Batch Chargeback Fee: ACH Reject Fee: Retrieval Fee: Voice Authorization Fee: Per Cal Gateway Access Fee: Gateway Transaction Fee: Annual Fee: Per Year Government Compliance Fee: TIN Mismatch Fee: Until Validated Voice AVS Fee: ARU Fee: Wireless Fee: PCI Annual Fee: Annual PCI Non-Compliance Fee: until compliant Clover & TransArmor Service Fee: TransArmor Data Protection Auth Fee Other Fees Start Mo/Yr. Amount Accept all MasterCard, Visa, Discover Network and American Express Transactions (presumed, unless any selections below are checked) MasterCard MC Credit Transactions MC Non-PIN Debit Trans. Discount Collected Daily Ach Detail Individual Visa Discover Network American Express VS Credit Transactions DISC Credit Transactions American Express VS Non-PIN Debit Trans. DISC Non-PIN Debit Trans. Credit Transactions Combined See Section 9 of the Program Guide for details regarding limited acceptance. Fees DISC/VS/MC/AMEX Transaction Fee: Non-Bankcard Transaction Fee: Sales Transaction Fee: Return Transaction Fee: Statement Fee: Minimum: Electronic AVS EBT Transaction Fee: EBT Statement Fee: Batch Fee: Per Batch Chargeback Fee: ACH Reject Fee: Retrieval Fee: Voice Authorization Fee: Per Call Gateway Access Fee: Gateway Transaction Fee: Annual Fee: Per Year Government Compliance Fee: TIN Mismatch Fee: Until Validated Voice AVS Fee: ARU Fee: Wireless Fee: PCI Annual Fee: Annual PCI Non-Compliance Fee: until compliant Clover & TransArmor Service Fee: TransArmor Data Protection Auth Fee: Other Fees Start Mo/Yr. Amount Wright Express: Other Item Rate $ Voyager: Qual % Other Item Rate $ Pin-Debit: Debit Transaction Fee Plus Network Fees Volume Percent % Wright Express: Other Item Rate $ Voyager: Qual % Other Item Rate $ Pin-Debit: Debit Transaction Fee Plus Network Fees Volume Percent % We understand and agree that while our Discount Rate as stated above will be charged on most electronically authorized payment card transactions batched and closed daily, charges up to 5% higher than my discount rate may apply where additional criteria is not met. Examples of where higher rates may apply, include but are not limited to, MOTO, keyed in transactions, transactions without AVS, business and foreign card transactions. Association Fees: The following Association Fees will be pass-through on all transactions. Visa Transaction Integrity Fee, Visa Risk ID, Visa Network Participation Fee (NPF), Visa NPF Card Present Surcharge, Visa NPF Card Not Present Surcharge, Visa Acquirer Processing Fee, Visa Misuse of Authorization Fee, Visa Zero Floor Limit Fee, Visa Int l. Acquirer Fee, Visa Acquirer ISA Fee, MC Acquirer Support Fee, MC Cross Border Fee, MC Nat l. Acquirer Brand Usage (NABU) Fee, MC Processing Integrity Fee, Discover Int l. Processing Fee, Discover Int l. Service Fee, Discover Data Usage Charge, Visa Processing Fee, MC Processing Fee, Visa BIN Fee, MC ICA Fee, MC License Fee, Visa Kilobyte Fee, Visa Kilobyte Fee Surcharge, MC Kilobyte Fee, MC Kilobyte Fee Surcharge. Please visit the Associations website for further details. An early cancellation fee of $495 will be paid to SignaPay if I/We terminate the agreement before the initial 3 year term as stated in Section A.3 of the program guide. Give name/address: (examples include, but not limited to hosting companies, shopping carts, Loyalty Programs, Electronic Data Capture). Please identify any software used for storing, transmitting or processing Card Transaction or Authorization requests. 8. American Express American Express ESA/Pass Through* American Express Pass Through SE#: American Express Discount Rate % Flat Per Transaction Fee $ American Express Prepaid Discount Rate % Flat Per Transaction Fee $ American Express Fee*: Flat Fee 9. Debit/Credit Authorization Include a voided check or bank letter verifying bank account information. *American Express Flat Fee or Discount Rate may apply. The 0.30% non-swiped fee is applied to any Charge for which American Express did not receive both (i) the full Magnetic Stripe and (ii) the indicator as to whether the Card was swiped. 0.30% downgrade will be charged by American Express for transactions whenever a CNP or Card Not Present Charge occurs. CNP means a Charge for which the Card is not presented at the point of purchase (e.g., Charges by mail, telephone, fax or the Internet). Note: The CNP Fee is applicable to transactions made on all American Express Cards, including Prepaid Cards. This fee applies to all American Express programs. Merchant authorizes SignaPay, Ltd. ( Processor ) or Wells Fargo Bank, N.A., ( Bank ) to present Automated Clearing House credits, Automated Clearing House debits, wire transfers, or depository transfer checks to and from the following account and to and from any other account for which Processor or Bank are authorized to perform such functions under the Merchant Processing Agreement, for the purposes set forth in the Merchant Processing Agreement. This authorization extends to such entries in said account concerning lease, rental or purchase agreements for POS terminals and/or accompanying equipment and/or check guarantee fees and amounts due for supplies and materials. This Automated Clearing House authorization cannot be revoked until all Merchant obligations under this Agreement are satisfied, and Merchant gives SignaPay written notice or revocation. DDA: ABA Routing: INVESTIGATIVE CONSUMER REPORT: An investigative or consumer report may be made in connection with application. MERCHANT authorized BANK or any of its agents to investigate the references provided or any other statements or data obtained from MERCHANT, from any of the undersigned individual credit or financial responsibility. You have a right, upon written request, to a complete and accurate disclosure of the nature and scope of the investigation requested. Average MC/Visa/Discover Ticket Size: Highest Ticket Amount: Average Annual MC/Visa Volume: Average Annual Discover Volume: Average Annual American Express Volume: Average American Express Ticket: (Estimate if Never Processed in Past) Each person certifies that the average ticket size and sales volume indicated is accurate and agrees that any transaction or monthly volume that exceeds either of the above amounts could result in delayed and/or withheld settlement of funds. IMPORTANT NOTICE: All information contained in this application was completed, supplied and/or reviewed by the undersigned Merchant. Process shall not be responsible for any change in printed terms unless specifically agreed to in writing by an officer of Processor and/or Wells Fargo Bank, N.A., Walnut Creek, CA. By signing below you are agreeing to the provisions stated within this merchant application, on the reverse side (the Merchant Agreement) and acknowledge receipt of the merchant operating guide. Those provisions must be read before signing. By signing below, you agree to the terms on the front and back of the MERCHANT Processing Agreement and the merchant operating guide.. Revised SignaPay is a registered ISO of Merrick Bank, South Jordan UT, Wells Fargo Bank, N.A., Walnut Creek, CA, Esquire Bank, Garden City, NY. Page 2 of 3

3 10. (s) 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 SignaPay1712(ia)] and Confirmation Page, which is part of this Merchant Processing Application (consisting of Sections 1-10), 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 the Merchant Processing Application and/or may leave a detailed voice message in the event the 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 hereby consents to receiving commercial electronic mail messages from us or our Affiliates 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 state in Section 3, Business Profile section above, your are authorized to accept transactions in accordance with the percentages indicated in that section. Client authorized SignaPay and Wells Fargo Bank, N.A. ( Bank ) and their affiliates to investigate the references, statements and other data contained herein and to obtain additional information from credit bureaus and other lawful sources, including persons and companies named in this Merchant Processing Application. Client authorizes SignaPay and BANK and their Affiliates (a) to procure information from any consumer reporting agency bearing his/her personal credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living, and (b) to contact all previous employers, personal references and educational institutions. Each of the undersigned authorizes us and our Affiliates to provide amongst each other the information contained in this Merchant Processing Application and Agreement and any information received from all references, including banks and consumer reporting agencies. It is our policy to obtain certain information in order to verify your identity while processing your account application. 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 SignaPay 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, and disclose such information to their agent, subcontractors, Affiliates and other parties for any purpose permitted by law. I authorize and direct SignaPay 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 American Express protects your privacy and how American Express 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 in the event I decline to receive marketing communications from American Express, I may continue to receive messages from American Express regarding American Express services. I understand that upon American Express s approval of the Application, as applicable, the entity will be provided with the Agreement and materials welcoming it to American Express s Card acceptance program. Client authorizes SignaPay and Bank and their affiliates to debit Clients 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 provided herein are 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 SignaPay and Bank. Client s Business Principal/Officer: Personal Guarantee: The undersigned guarantees to SignaPay and Bank the performance of this Agreement and any addendum thereto by Client, and in the event of default, hereby waives Notice of Default and agrees to indemnify the other parties, including payment of all sums due and owing and costs associated with enforcement of the terms thereof. SignaPay and bank shall not be required to first proceed against Client or enforce any other remedy before proceeding against the undersigned individual. The term of this guarantee shall be for the duration of the Merchant Processing Application and Agreement and any addendum thereto, and shall guarantee all obligations which may arise or occur in connection with my activities during the term thereof, though enforcement may be sought subsequent to any termination. Personal Guarantee Accepted By SignaPay Wells Fargo Bank, N.A., 1200 Montego Way, Walnut Creek, CA Revised SignaPay is a registered ISO of Merrick Bank, South Jordan UT, Wells Fargo Bank, N.A., Walnut Creek, CA, Esquire Bank, Garden City, NY. Page 3 of 3

4 4100 W. Royal Lane, Suite 150 Irving, TX Revised

5 Equipment Order / Download Setup Form Please fax to (214) Payment Type Welcome Kit Instructions : SALE SHIP TO MERCHANT REPROGRAM SHIP TO AGENT LEASE DO NOT SHIP INVENTORY TPG TASQ FOR INTERNAL USE ONLY CYNERGY OTHER SalesOffice Information SALES / ISO OFFICE #: Mechant and Shipping Information MID#: Sales Office Name: DBA NAME: Sales Rep Name: SHIP TO ADDRESS: Sales Rep #: CITY: STATE: ZIP: TELEPHONE: FAX: 1 Manufacturer Model QTY Price Platform Application Type FIRST DATA RETAIL Total Equipment Sale: $ Omaha North Nashville Buypass RESTAURANT Leasing Options TSYS LODGING Lease Payment: $ CYNERGY DATA Paymentech Tsys MOTO SUPERMARKET Connection Type PETROLEUM Total Lease Amount: $ DIAL (FIRST DATA ONLY) IP / HIGH SPEED INTERNET Terminal Prompts Delivery Amount: $ Debit/EBT FRAUD CONTROL DEBIT INTERNAL EXTERNAL AVS Taxes: $ EBT FCS# CVV2 TIP LINE Batching Options TIP PROMPT Grand Total $ SERVER PROMPT INVOICE PROMPT X Months AUTO BATCH TIME: MANUAL BATCH Software / Gateway (specify type) Delivery Method Delivery Price NEW Ground ( 1 piece = $15, 2 piece = $20 ) ( 1 piece = $25, 2 piece = $30 ) ( 1 piece = $45, 2 piece = $55 ) EXISTING 2nd Day Delivery Overnight Payment Method ACH from my Account ABA Routing #: Account #: Check Enclosed (Print Name) () Credit Card Visa Mastercard AMEX Discover Card Billing Address Name on Card: Card Number: ADDRESS: CITY: Expiration : / / CVVS ZIP: Special Instructions STATE: / / ()