MERCHANT INFORMATION SHEETFEDERAL TAX IDLEGAL BUSINESS NAMEBUSINESS DBABUSINESS START DATEBUSINESS ADDRESSBUSINESS CITY, STATE, ZIPBUSINESS TELEPHONEBUSINESS FAXBUSINESS WEBSITEBUSINESS E-MAILLANDLORD NAME AND #TRADE REFERENCE 1 W/ PHONE #TRADE ACCOUNT # W/ CONTACTTRADE REFERENCE 2 W/ PHONE #TRADE ACCOUNT # W/ CONTACTBUSINESS BANK NAME W TEL #BANK ACCOUNT #BANK ROUTING #EBT FOOD STAMPS FNS #CURRENT AMEX MERCHANT #CURRENT DISCOVER MERCHANT #OTHER CARD TYPE(S) #CURRENT CC PROCESSORMONTHLY CREDIT CARD VOLUME% SWIPED TRANSACTIONSAVERAGE CREDIT CARD AMOUNTBUINSINESS OWNER NAMEDATE OF BIRTHSOCIAL SECURITY NUMBEROWNER’S HOME ADDRESSOWNER’S CITY, STATE, ZIPDRIVERS LICENSE #MOBILE TELEPHONEPROCESSING ENVIRONMENTIPDIALWIFICOMMUNICATIONCURRENT POS EQUIPTMENTPURCHASE POS / CARD TERMINALREQUESTED CARD TERMINAL3.5SURCHARGE FEE %CASH BACK ON TERMINALPIN PADINDUSTRY TYPETIPSAUTO CLOSE YESBATCH TIMENOGATEWAY SET UP NEEDEDNETWORK NEEDEDOMAHANORTHTSYSNASHVILLECARD PRESENT %CARD NOT PRESENT %MONTHLY CREDIT CARD VOLUMESTATEMENTSVOIDED CHECKMOBILEBUYPASSFINANCIALSPlease fill in the form and sign, date and send back to: [email protected] orfax to 1.877.599.5741Please call with any questions 858.939.0078 Thank You!
OmahaWF1904M E R C H A N T P R O C E S S I N G A P P L I C AT I O N A N D AG R E E M E N TOmahaWF1910(ia)Sales Office Print Sales Rep Name Sales ID #Merchant Number Sales Rep. Signature Phone #:Client’s Business Name (Doing Business As):Business Address:City:Page 1 of 51. B U S I N E S S I N F O R M AT I O NClient’s Corporate/Legal Name (Use Also For Headquarter’s Information):State:Location Phone #:Location Fax #:Business E-mail Address:Business Website Address:Customer Service Phone #:Billing Address (If Different Than Location Address):Zip:City:Contact Name:Assumed Name Filed: State: CORPORATION – CHAPTER S, CState:Contact Phone #: Business Location Corp/Legal LocationSend Retrieval Requests to:Send Merchant Monthly Statement to: Business Location Corp/Legal LocationDate Business Started: TAx ExEMPT ORGANIZATION (501C) State: INTERNATIONAL ORGANIZATIONLocation Filed: ASSOCIATION /ESTATE / TRuST State Filed: MEDICAL OR LEGAL CORPORATION State:Name (as it appears on your income tax return)Zip:Contact Fax # / E-mail Address:Customer Service E-mail Address: INDIVIDuAL /SOLE PROPRIETORSHIP: State in which Certificate ofState:(as it appears on your income tax return)FEDERAL TAX ID # GOVERNMENT (Federal, State, Local) LIMITED LIABILITYCOMPANYState Filed: PARTNERSHIPState Filed: I certify that I am a foreign entity/nonresident alien.(If checked, please attach IRS Form W-8.)NOTE: Failure to provide accurate information may result in a withholding of merchant funding per IRS regulations. (See Part IV, Section A.4 of your Program Guide for further information.)*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 78411,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 feescould be 1,000.00). Failure to register could result in fines in excess of 10,000.00 for violating Visa and/or MasterCard regulations2.1Registration for MCC 7841 is only required for non-face-to-face adult content.2 Information herein, including applicable MCCs, is subject to change.Detailed Explanation of Type of Merchandise, Products or Services Sold:1.2.Zone:2 . A D D I T I O N A L C R E D I T / S I T E S U RV E Y I N F O R M AT I O N – A L L M E R C H A N T S Business District Industrial Apartment IsolatedLocation: Mall Office Flea Market Home Other3.How many employees:5.Is proper license visible? Yes126.96.36.199.9. Residential Shopping Area Door-to-Door 0-3 No, explain:Where is the merchant name displayed at the site? Door Store FrontMerchant Occupies: Ground Floor# of Floors/Levels: 1 2-4Remaining Floor(s) Occupied by: Other: 5 - 10 11 Residential Commercial Combination None 0 -250 251-500 501-2,000 2,001 plus10. Approximate Square Footage:11. Are customers required to leave a deposit? No Yes12. Return Policy:If Yes, % of deposit required: % Full Refund Yes No If yes, check one: Exchange MC/ Visa /Discover Network - PayPal /American Express OptBlue Credit Store CreditIf MC/ V /Discover Network - PayPal /American Express OptBlue Credit, within how manydays do you submit credit transactions?How many registers / Terminals: Window13. Do you have a refund policy for MC/ Visa /Discover Network - Paypal / American Express OptBlue Sales? Exchange Only None 4-7 8 - 14 Over 1414. Advertising Method (Attach at least one): Catalog Brochure Direct Mail Internet Phone Newspaper/JournalsMarketing Materials required for Mail Order, B to B, Internet over 1 Million in annual volume. Attach Web Page for Internet Merchant. TV / Radio Other15. Previous Processor:16. Check Reason For Leaving: Rate Service Terminated Other:(All Questions must be Answered)Mail / Telephone Order / Business to Business / Internet Information1.What is the time frame from transaction to delivery? (% of orders delivered in):2.MC/ Visa /Discover Network - PayPal /American Express OptBlue sales are deposited (check one):3.0 - 7 days % 8 - 14 days % 15 - 30 days % over 30 days % 100% Date of order Date of delivery Other (specify):Does any of your cardholder billing involve automatic renewals orrecurring transactions (i.e., cardholder authorizes initial sale only) ? Yes NoMerchant Initials:
DBA Name:OmahaWF1904Name: (First, MI, Last)Title:Home Address: (No P.O. Box)City:Telephone #:D.O.B.:State:Zip: IndividualCountry:Social Security #:% Ownership:State:Home Address: (No P.O. Box)City:Telephone #:D.O.B.:State:Zip:Social Security #:DL #:Country:State:4 . S E T T L E M E N T I N F O R M AT I O NDeposit Bank:ACH Detail Flag:Page 2 of 5OmahaWF1910(ia)Title:DL #:Transit / ABA #:Merchant #:3 . OW N E R S / PA RT N E R S / O F F I C E R SOWNER / PARTNER / OFFICER 1OWNER / PARTNER / OFFICER 2% Ownership: Name: (First, MI, Last) CombinedDeposit Account #: Separate (defaults to Combined if option not selected)5 . T R A N S AC T I O N I N F O R M AT I O NFINANCIAL DATAGross YEARLY Sales Volume(Cash Credit Debit Check)Average YEARLY Discover Network PayPal VolumeAverage YEARLY MC/ Visa Volume Avg. MC/ Visa /Discover Network PayPal Ticket (Estimate If Never Processed in Past) Highest Ticket Amount Avg. American ExpressOptBlue Ticket (Estimate If Never Processed in Past) Average YEARLY American ExpressOptBlue Volume Seasonal? No Yes High Volume Months Open:WHERE IS SALETRANSACTED?(Must 100%)Store Front /Swiped%Mail Order%Internet%Telephone Order%100%Total6 . G R I D I N F O R M AT I O N – I N T E R N A L U S E O N LYAuTHORIZATION GRID ID #:MC TIEREDGRID IDMC CREDITMPG IDMC DEBITMPG ID8-pos. Alpha /NumericVISA TIEREDGRID ID8-pos. Alpha /NumericVISA DEBITMPG ID8-pos. Alpha /NumericVISA CREDITMPG IDuSER DEFINED GRID ID #:MFC GRID ID: 8-pos. Alpha /Numeric8-pos. Alpha /NumericDISCOVER NETWORK - PayPalTIERED GRID ID8-pos. Alpha /Numeric8-pos. Alpha /NumericDISCOVER NETWORKDEBIT MPG ID8-pos. Alpha /Numeric8-pos. Alpha /NumericDISCOVER NETWORK - PayPalCREDIT MPG ID8-pos. Alpha /NumericAMERICAN ExPRESSOptBlue TIEREDGRID ID8-pos. Alpha /NumericAMERICAN ExPRESSOptBlue CREDITMPG ID8-pos. Alpha /Numeric7 . S E RV I C E F E E S C H E D U L EAccept all MasterCard, Visa, Discover Network and American Express OptBlue Transactions (presumed, unless any selections below are checked)MasterCardVisaDiscover NetworkAmerican Express OptBlue MC Credit Transactions Visa Credit Transactions Discover Network Credit Transactions American Express Credit Transactions MC Non-PIN Debit Trans. Visa Non-PIN Debit Trans. Discover Network Non-PIN Debit Trans. Daily Discount CollectedDiscover Network - PayPal Discover Network - PayPal Credit Transactions MonthlyTieredDiscount Fees (Based on Gross Sales Volume)MCQual CreditDiscountMCMid-Qual Credit3.5MC WorldcardQual3.5MC WorldcardNon-Qual3.5MCMid-Qual Debit3.5MC RegulatedDebit Discount3.5MCNon-Qual Credit3.5MC WorldcardMid-Qual3.5MCQual Debit3.5MCNon-Qual Debit3.53.5MPG TxN Fee% VisaQual Credit% VisaNon-Qual Credit% % % % VisaMid-Qual CreditVisa Rewards 188.8.131.52% Discover Network PayPal Qual Credit% Discover Network PayPal Non-Qual Credit% % 3.5% American ExpressOptBlue Non-Qual CreditDiscover NetworkMid-Qual Debit3.5% Discover NetworkRegulated Debit Disc’t3.5VisaMid-Qual Debit% Discover NetworkQual DebitVisa RegulatedDebit Discount3.5% Discover NetworkNon-Qual Debit% 3.53.5% % MPG TxN Fee% Discover Network PayPal Mid-Qual Credit3.5VisaNon-Qual DebitDiscountAmerican ExpressOptBlue Qual Credit% VisaQual Debit% 3.5MPG TxN Fee3.5Visa Rewards 2% % Discount184.108.40.206.5% American ExpressOptBlue Mid-Qual CreditDiscount220.127.116.11MPG TxN Fee% % % % % % Merchant Initials:
DBA Name:OmahaWF1904ERRMC Qual CreditDiscount%DiscountNon-Qual Fees% Visa Qual Credit%Non-Qual Fees%%% Visa Qual Debit% Pass Through Interchange - Includes Dues and AssessmentsMC Qual DebitMC Qual CreditDiscount (Basedon Gross Sales Vol.)% Visa Qual CreditOther Item RateMC DebitOther Volume % Pass Through Debit Network FeesOther Item Rate.25(per item) %American ExpressOptBlue Credit %Dec. Risk Surcharge%.10% Dues and AssessmentsPer TxN Fee %Other Volume Percent3.89%Other Item RateMonthly Minimum Fee (Per Location)2.50Customer Requested Operator Call (CROC) V /MC ChargebackFee(Per Item) V /MC Retrieval5Fee (12B Letter) (Per Item) Early Termination499Fee(One Time Fee) EBT –.25Cash Benefits(Per Item) Miscellaneous FeesSales Transaction.10.25Fee(Per Item) Batch Fee(Per Item) EBT –.25Food Stamps(Per Item) #:Monthly Statement Fee25Minimum Monthly Fee (Acct on File) ACH Reject Fee10MC License Fee.02.02(Per Sales Item) (Sales Volume) %.02Visa Proc Fee(Per Item) Pass Visa Fixed Acquirer Yes NoNetwork Fee (FANF)Pass Visa Yes NoAcquirer Processing Fee5.00 Stmt /Processing Fee.02(Per Item) MC Proc FeeVisa BIN Fee%Discount (Basedon Gross Sales Vol.)50(Per Item) (Flat Rate) .02(Per Item) % American ExpressOptBlue Credit ECA Warranty Mail Order Warranty Single Hold Check Warranty Multiple Hold Check Warranty Paper Warranty C.O.D. WarrantyInquiry RateNon-Qual FeesAmerican Express OptBlue has Program Pricing and notInterchange and are subject to change. FleetTeleCheck%%% American Express OptBlue Qual Credit.25 (per item)Voyager: QualDiscountAmerican ExpressOptBlue Qual Credit%Discount (Basedon Gross Sales Vol.)Page 3 of 5OmahaWF1910(ia)Non-Qual Fees%Discover Network % PayPal CreditDiscover Network% DebitPIN Debit% Visa DebitWEX: Other Item Rate%Discover Network PayPal CreditDiscover NetworkDebit % Visa CreditMC DebitDiscount% Discover Network Qual DebitVisa DebitMC CreditDiscover Network PayPal Qual CreditDiscover NetworkQual Debit% Discover Network - PayPal Qual CreditVisa Credit %Discount (Basedon Gross Sales Vol.)% Visa Qual DebitMC Qual DebitMC CreditMerchant #:7 . S E RV I C E F E E S C H E D U L E (cont’d)%3.50% (per item).25(per item) SE #ECA Chargeback Fee5.00 Return Trans.Fee(Per Item) .25MC ICA Fee.02(Per Item) 10elDS Access Fee (Flat Rate) Other: Pass Visa Yes NoTrans Integrity Fee Monthly Annually in December.02.02Visa FANF Card Present Surcharge (Flat Rate) Visa FANF Card Not Present Surcharge (Flat Rate) Pass VisaPass VisaPass Visa Yes No Zero Floor Limit Fee Yes No Int’l Acquirer Fee Yes NoMisuse of Auth FeePass MCPass MCPass DiscoverPass Visa Yes No Cross Border Fee Yes No Data usage Charge Yes No Acq ISA Fee Yes NoAcquirer Support FeePass MCPass DiscoverPass DiscoverPass MC Nat’l Acquirer Yes No Int’l Proc Fee Yes No Int’l Service Fee Yes No Brand usage (NABu) Fee Yes NoProc Integrity FeeFirst Data Payeezy SMAuthorization & Capture Transaction FeesFirst Data Payeezy SM Gateway ServicesGateway Services Telecheck Payeezy Gateway Participation.25(per item)MC/ Visa Auth & Capture Fee: Discover Network PayPal Auth & Capture Fee:.25(per item) .25American Express OptBlue Auth & Capture Fee: (per item)American ExpressPass Through (existing) SE #:Voice Authorization(per item) 1.75Electronic AVS Fee.05 (per item)ARu Fee1.50 (per item)Voice AVS FeeWireless Monthly Service FeeCustomer Service Fee1.95 (per item)Payeezy Gateway Effective Date:Payeezy Gateway One Time Setup Fee (one time)Payeezy Gateway Monthly Fee (monthly)Payeezy Gateway AVS Fee (per item)Payeezy Gateway Auth FeePayeezy PayPal Auth FeePayeezy PayPal Sale FeePayeezy PayPal Return FeeUser Defined Grid Fees15 12 Supplies: AccessOne FeeDebit Access Fee (per item) (per item) (per item) (per item)Payeezy GatewayTeleCheck Auth Fee10 Payeezy GatewayTeleCheck Deposit Fee Payeezy GatewayTeleCheck Adjustment Fee (per item)(per item)(per item)TIN / TFN & Regulatory Product Fees10 Other: Reg. Product Fee3.95(Monthly) Website usage(Per Item) TIN / TFN Invalid10.00(Monthly) Merchant Initials:
DBA Name:OmahaWF1904Annual Fee99 MonthPass Visa File Transmission FeeOther: Per item Monthly AnnuallyPass Visa Acquirer Credit Voucher Data Processing FeePass American Express OptBlue Network FeeAmerican Express Dispute FeePass MasterCard Kilobyte FeeDiscover Retrieval Fee Yes No Yes No(Flat Rate) (Sales Volume) .10%.05(Flat Rate) 5(Flat Rate) 19(Flat Rate) 9(Flat Rate) Jeanie Debit Network Annual Fee Surcharge16(Flat Rate) Accel Debit Network Annual Fee Surcharge13(Flat Rate) 10(Flat Rate) (Flat Rate) (Per Item) (Flat Rate) TransArmor DataProtection Fee(Flat Rate) Wireless Activation Fee(Flat Rate) Payeezy Webstore SolutionMonthly Fee (per webstore) (Flat Rate) (For the Perka Solution, you will be provided with registration instructions and will be asked to electronically agree toPerka Inc.’s terms and conditions)(Flat Rate) Per Chargeback DCC Retrieval FeePer Retrieval DCC Transaction Fee8 . E Q U I P M E N T / T H I R D PA RT Y I N F O R M AT I O N Nashville BuypassDo you use any third party to store, process or transmit cardholder data?If yes, identify the Third Party Processor used: 00 None 07 Apriva First Data Global Gateway(Sales Volume) .10%NYCE Debit Network Annual Fee Surcharge Yes No(Flat Rate) North.05(Per Item) TransArmor SolutionPCI Only FeeWireless MonthlyService FeeInsightics SolutionMonthly Fee (per MID)(Flat Rate) OmahaMasterCard ICA AVS Fee Surcharge.05(Flat Rate) or (Per Item) Pulse Debit Network Annual Fee Surcharge Yes NoPass Accel Debit Network Annual Fee.02(Flat Rate) or (Per Item) STAR Debit Network Annual Fee Surcharge Yes NoPass NYCE Debit Network Annual FeeMasterCard Kilobyte Fee SurchargeMasterCard Location Fee Surcharge Yes NoPass Jeanie Debit Network Annual Fee5(Per Item) MasterCard SecureCode Transaction Fee Surcharge Yes NoPass Pulse Debit Network Annual Fee(Sales Volume) 15%MasterCard Business to Business uS Surcharge Yes NoPass STAR Debit Network Annual FeeAmerican Express OptBlue Network Fee SurchargeMasterCard Digital Enablement Fee Surcharge Yes NoPass MasterCard Location Fee5(Per Item) (Sales Volume) %MasterCard CVC2 Fee Surcharge Yes No.09(Flat Rate) or (Per Item) PayPal Participation Authorization Fee SurchargeAmerican Express Retrieval Fee Yes NoPass MasterCard SecureCode Transaction FeeINTERNET GATEWAY:Discover Network Auth Fee Surcharge Yes NoPass MasterCard Business to Business uSNetwork (Front End):.10(Per Item) (Per Item) Pass MasterCard Digital Enablement FeeDCC Chargeback FeeVisa AFD Non Participation Fee Surcharge Yes NoPass MasterCard ICA AVS FeeTransArmor SolutionFull Bundle FeeClover Service FeeMonthly (per station)Clover Go Monthly Fee(per MID)Perka Solution Monthly Fee(per MID) Yes No Yes NoPass MasterCard CVC2 FeeMonth.10(Per Item) Visa Acquirer Credit Voucher Data Processing Fee Surcharge Yes NoPass American Express OptBlue Access Fee Per item Monthly Annually .02(Flat Rate) (Per Item) Pass PayPal Participation Authorization FeeOther:Visa File Transmission Transaction Fee Surcharge Yes NoDiscover Dispute FeeMonthPage 4 of 5OmahaWF1910(ia) Yes No Yes NoPass Visa AFD Non Participation FeePass Discover Network Auth FeeMerchant #:7 . S E RV I C E F E E S C H E D U L E (cont’d)Merchant Fee Control Grid Fees 01 Yahoo 08 FIS Yes No 02 Authorize.net 03 Cybersource 09 Six Payment Services Corp 04 Verifone 10 VerisignPer Settlement 05 Merchant Link 06 Shift 4 99 Other (please specify) Other:Wireless Network:PC/ Internet SoftwareQuantity New Rent Lease ExistingQuantity New Rent Lease ExistingTerminal ModelQuantityPIN PadQuantityPrinter Model New New Rent Rent Lease Lease Existing ExistingMerchant Initials:
C O N F I R M A T I O t Data M e r c h a n t S e r v i c e sAddress: 1307 Walt Whitman Road, Melville, NY 11747C u s t o m e r Service #:URL:1-800-858-1166P l e a s e read t h e P r o g r a m G u i d e in its entirety. It d e s c r i b e s t h e t e r m s u n d e r w h i c h we will provide m e r c h a n t p r o c e s s i n g S e r v i c e s to you.F r o m t i m e t o t i m e you m a y have q u e s t i o n s regarding t h e c o n t e n t s o f y o u r A g r e e m e n t with Bank and/or P r o c e s s o r o r t h e c o n t e n t s o f y o u rA g r e e m e n t w i t h T e l e C h e c k . T h e following i n f o r m a t i o n s u m m a r i z e s p o r t i o n s o f y o u r A g r e e m e n t i n o r d e r t o assist you i n a n s w e r i n g s o m e o f t h eq u e s t i o n s w e are m o s t c o m m o n l y asked.1.Your D i s c o u n t Rates are a s s e s s e d on transactions that qualify forcertain reduced interchange rates imposed by MasterCard, Visa,Discover and PayPal. Any transactions that fail to qualify for thesereduced rates will be charged an additional fee (see Section 25 of theProgram Guide).2.We m a y d e b i t y o u r bank a c c o u n t (also referred to as your SettlementAccount) from time to time for amounts owed to us under the Agreement.3.T h e r e are m a n y reasons why a Chargeback m a y occur. When theyoccur we will debit your settlement f u n d s or Settlement Account. For amore detailed discussion regarding Chargebacks see Section 14 of theYour Payments Acceptance Guide or see the applicable provisions of theTeleCheck Services Agreement.4.If you d i s p u t e any c h a r g e or funding, you must notify us within 60days of the date of the statement where the charge or funding appearsfor Card Processing or within 30 days of the date of a TeleChecktransaction.5.T h e A g r e e m e n t limits o u r liability to you. For a detailed descriptionof the limitation of liability see Section 27, 37.3, and 39.10 of the CardGeneral Terms; or Section 1.14 of the TeleCheck Services Agreement.We have a s s u m e d c e r t a i n risks by agreeing to provide you with Cardprocessing or check services. Accordingly, we may take certain actions tomitigate our risk, including termination of the Agreement, and/or hold moniesotherwise payable to you (see Card Processing General Terms in Section 30,Term; Events of Default and Section 31, Reserve Account; Security Interest),(see TeleCheck Services Agreement in Sections 1.1, 1.3.2, 1.3.9, 1.6), undercertain circumstances.By e x e c u t i n g this A g r e e m e n t w i t h us you are authorizing us and ourAffiliates to obtain financial and credit information regarding your businessand the signers and guarantors of the Agreement until all your obligations tous and our Affiliates are satisfied.8.T h e A g r e e m e n t c o n t a i n s a provision that in the event you terminate theAgreement prior to the expiration of your initial three (3) year term, you willbe responsible for the payment of an early termination fee as set forth in PartIV, A.3 under "Additional Fee Information" and Section 1 of the TeleCheckServices Agreement.9.If you lease e q u i p m e n t f r o m Processor, it is important that you reviewSection 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 O r g a n i z a t i o n D i s c l o s u r eVisa and MasterCard M e m b e r Bank l n f o r m a t i o n : W e l l s Fargo Bank N . A .The Bank's mailing address is 1200 Montego, Walnut Creek, CA 94598, and its p h o n e n u m b e r is (925) 746-4143.I m p o r t a n t M e m b e r Bank Responsibilities:I m p o r t a n t M e r c h a n t Responsibilities:a) The Bank is the only entity approved to extend acceptance of Visaand MasterCard products directly to a merchant.a) Ensure compliance with Cardholder data security and storage requirements.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 Visaand MasterCard rules with which merchants must comply; but thisinformation may be provided to you by Processor.d) Comply with Card Organization Rules and applicable law and regulations.d) The Bank is responsible for and must provide settlement f u n d s tothe merchant.e) The Bank is responsible for all f u n d s held in reserve that arederived from settlement.0The Bank is the ultimate authority should a merchant have anyproblems with Visa or MasterCard products (however, Processoralso will assist you with any such problems).e) Retain a signed copy of this Disclosure Page.D You may download "Visa Regulations" from Visa's website at:https://usa.visa.com/support/mcrchant.html.g) You may download "MasterCard Regulations" from MasterCard's website at:hup://wwwmaMerc3rd r com/us/mgrchflnt/suppprl/rules.html.h) You may download "American Express Merchant Operating Guide" fromAmerican Express' website at: www.americanexpress.com/merchantopguide.Print Client's B u s i n e s s Legal N a m e :By its signature below, Client a c k n o w l e d g e s t h a t it has r e c e i v e d t h e M e r c h a n t P r o c e s s i n g Application, P r o g r a m T e r m s and C o n d i t i o n s [versionO m a h a W F I 9 0 4 ( i a ) ] c o n s i s t i ng of 52 p a g es [including this C o n f i r m a t i on Page and t he applicable Third Party A g r e e m e n t ( s ) ] .Program Terms and Conditions located at: /2016/11/Program-Guide-1904-Omaha.pdfClient f u r t h e r a c k n o w l e d g e s reading and a g r e e i n g to all t e r m s in t h e P r o g r a m T e r m s and C o n d i t i o n s . U p o n r e c e i p t of a s i g n e d facsimile ororiginal of this C o n f i r m a t i o n Page by us, Client's Application will be p r o c e s s e d .N O ALTERATIONS O R S T R I K E - O U T S T O T H E P R O G R A M T E R M S A N D C O N D I T I O N S W I L L B E A C C E P T E D .Client's Business Principal:S i g n a t u r e (Please sign below):XTitleP l e a s e Print N a m e of S i g n e rOmahaWF1904(ia)Date
DBA Name:OmahaWF1904LEASE COMPANY:Merchant #:8 . E Q U I P M E N T / T H I R D PA RT Y I N F O R M AT I O N (cont’d)(04) First Data Global LeasingAnnual Tax Handling Fee: AL, AR, CA, CT, GA, IN, KY, LA, MS, MO, NE, NV, NM,30.20NC, OK, OR, RI, SC, TN, Tx, VT, VA, WA, WV, WI, WYPage 5 of 5OmahaWF1910(ia) All otherStates10.20Total Monthly Lease Charge: Total Cost To Lease (without tax): AddressStateLease Term: Mos.BanktoCopy- White SalesCopy please- Yellow MerchantCopy 1-877-257-2094- PinkOption to purchase: If you wishbuyoutthe Representativeequipment,contactto obtain the cost.(w/o taxes, late fees, or other charges that may apply – See Lease Agreement in Program Guide for details. This is a non-cancelable lease for the full term indicated.)CityZipAttention:9 . S I G N AT U R E ( 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 Guideand Confirmation Page, which is part of this Merchant Processing Application (consisting of Sections 1-9), and by this reference incorporated herein. Client acknowledgesand agrees that we, our Affiliates and our third party subcontractors and/or agents may use automatic telephone dialing systems to contact Client at the telephonenumber(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 ifthe 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 solicitationpurposes. Client hereby consents to receiving commercial electronic mail messages from us, our Affiliates and our third party subcontractors and/or agents from time totime. 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 approvedbased upon contrary information stated in Section 8, Transaction Information section above, you are authorized to accept transactions in accordance with the percentagesindicated in that section. This signature page also serves as a signature page to the Equipment Lease Agreement, and the TeleCheck Services Agreement appearing in theThird Party Section of the Program Guide, if selected, the undersigned Client being the “Lessee” for purposes of such Equipment Lease Agreement and/or “You” and “Your”for the purposes of the TeleCheck Services Agreement.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 thisApplication and to request and obtain from any consumer reporting agency and other sources, including bank references, personal and business consumer reports andother information and to disclose such information amongst each other for any purpose permitted by law. If the Application is approved, each of the undersigned alsoauthorizes us, our Affiliates and our third party subcontractors and/or agents to obtain subsequent consumer reports and other information from other sources, includingbank references, in connection with the review, maintenance, updating, renewal or extension of the Agreement or for any other purpose permitted by law and disclose suchinformation amongst each other. Each of the undersigned furthermore agrees that all references, including banks and consumer reporting agencies, may release any andall personal and business credit financial information to us, our Affiliates and our third party subcontractors and/or agents. Each of the undersigned authorizes us, ourAffiliates and our third party subcontractors and/or agents to provide amongst each other the information contained in this Merchant Processing Application and Agreementand any information received subsequent thereto from all references, including banks and consumer reporting agencies for any purpose permitted by law. It is our policyto 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 gatheredonline or that you submit to us, and/or automated electronic computer security screening, by us or our third party vendors.Client authorizes FDMS and Bank and their affiliates to debit Client’s designated bank account via Automated Clearing House (ACH) for costs associated with equipmenthardware, 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 unlawfulInternet 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 certainjurisdictions 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 shallnot take effect until Client has been approved and this Agreement has been accepted by FDMS and Bank.Client’s Business Principal/Officer:Signature X TitlePrint Name of Signer Date(Servicers): For First Data Merchant Services LLCand Wells Fargo Bank, N.A.,(a member of Visa USA, Inc.and MasterCard International, Inc.)Print Name of Signer DateX SignatureSignature X TitleSignature X TitlePrint Name of Signer DateTELECHECK ACH AUTHORIZATIONACH Debit and Credit Authorization: Client authorizes its Financial Institution to pay and charge to its account the amount(s) due TeleCheck under this TeleCheckAgreement and to accept all credits and debits
federal tax id . legal business name . business dba . business address . business city, state, zip . business telephone . business fax . business website . business e .