Paysafe Merchant Processing Application Online

Required New Application
MERCHANT PAYMENT CARD APPLICATION/AGREEMENT
Woodforest National Bank
P.O. Box 8339 The Woodlands, TX 77387 Ph.: (800) 327-0093

New AccountAdditional Location Main Location MID:Ownership Change Previous Owner’s MID:
MERCHANT INFORMATION
I. BUSINESS INFORMATION (ALL FIELDS IN THIS SECTION ARE MANDATORY)
First Name*
Last Name*
Type of Ownership:*

LLC / LLPCorporationSole ProprietorPartnershipNon-Profit
DBA:*
Legal Business Name:*
Number of Locations:*
Product / Service Sold:*
CORPORATE ADDRESS
IS THE CORPORATE ADDRESS THE SAME AS THE PHYSICAL ADDRESS*

YesNo
Company Address*

Address: (No P. O. Box)

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Company Phone:*
Company Fax:
PHYSICAL ADDRESS
Address:
City, State, Zip:
Phone:
Fax:
Company Email:*
example@example.com
Website:*
Do you currently accept Visa/MC/Discover® Network?*

YesNo
Date Business Started (Mo/Yr):*

MonthDayYear
Date
II. PROCESSING VOLUME
Average Ticket Amount*
Enter the average sale amount.
Typical High-End Ticket*
Enter the highest sale amount you would receive in one transaction.
Monthly Bank Card Volume*
Enter the average monthly volume in credit cards excluding Amex.
Monthly AMEX Volume*
Enter the average monthly volume in American Express only.
Annual Volume*
Enter the yearly volume in total credit cards including Amex.
Agent #:
ISO Name:
Agent Name:
DBA:
FRONT END EQUIPMENT

FDR OmahaFDR NashvilleFDR NorthTSYSBuypassPaymentech
BACK END EQUIPMENT

FDR OmahaFDR NorthTSYS
Equipment Deployment/Ordering
Quantity
Type
Ship To Name and Address
Notes:
Agent #:
MCC SIC Code:
Indicate if Classified as:

Small BusinessDisadvantaged Business
Number of Locations:
Percent of Business (MUST = 100%)
% Card Swiped / EMV
% Keyed (Card Present)
% Keyed (Card Not Present)
Sales Method (MUST = 100%)
Store Front (Cardholder Present)
% Mail / Phone Order
% Internet Services (eCommerce)
III. PRODUCT ADVERTISING, SALES, AND DELIVERY - - REQUIRED QUESTIONS 1-9 MUST BE ANSWERED - MOTO QUESTIONS – 1-17 MUST BE ANSWERED
1. Description of product sold:
2. How does the customer purchase/order the product?

In PersonBy MailBy PhoneBy FaxInternet100% Paid in Advance100% Paid Upon Delivery / Completion
3. What is the delivery time frame to the consumer?

0-7 days8-14 days15-30 days30+ days
4. What is your return, cancellation, or refund policy?
5. What percentage of your business is Deposits and Future Services:
% Cash & Carry?
6. In what geographic areas will the product be marketed and sold?
7. What percentage of sales transactions are with international cards?
8. Who owns product?

MerchantVendor (Drop Ship Required)
9. Are consumers required to provide a deposit?

NoYes Percentage:
Yes Percentage:
10. Name of fulfillment house, if any:
11. At what point is consumer paid in full?

100% Paid in Advance100% Paid Upon Delivery / Completion
12. When you receive an authorization, how long before the merchandise is shipped?
13. List the name(s) and address(es) of vendor(s) from whom the product is purchased:
14. What shipping service do you use to deliver products to consumers?

Fed ExUPSAirborneUSPS Express
15. How do you advertise?

CatalogTV or RadioDirect Mail/FlyersInternet
16. What is your warranty/guarantee? Provide description:

By MerchantBy Manufacturer
Provide description:
17. Is your business seasonal?

YesNo
Start Month
End Month
18. Does your business accept incremental payments?

Yes
1st Payment %
2nd Payment %
3rd Payment %
4th Payment %
III. ASSOCIATION DISCLOSURE (Visa and MasterCard Member Bank: Woodforest National Bank, P.O. Box 9243, The Woodlands, TX 77387, (877) 525-5113)

Association Disclosure: Merchant Understands and Agrees to the Following Language Regarding Responsibilities: Member Bank Responsibilities: (1) A VISA member is the only entity approved to extended acceptance of VISA products directly to a merchant. (2) A VISA member must be a principal (signer) to the Merchant Agreement. (3) Wood forest National Bank is responsible for and must provide settlement funds to the merchant. (4) Woodforest National Bank is responsible for all funds held in reserve that are derived from settlement. (5) Woodforest National Bank is responsible for educating merchants on pertinent VISA International Operating Regulations with which merchants must comply. Merchant Responsibilities: (1) Ensure compliance with cardholder data security and storage requirements. (2) Maintain fraud and chargebacks below thresh olds. (3) Review and understand the terms of the Merchant Agreement. (4) Comply with VISA International Operating Regulations. (You may download “Visa Regulations” from Visa’s website at: http://usa.visa.com/merchants/operations/op_regulations.html You may download “MasterCard Regulations” from MasterCard’s website at https:// www.mastercard.us/content/mccom/en-us/merchants.html/: The responsibilities listed above do not supersede the terms of the Merchant Agreement and are provided to ensure that the merchant understands some of the important obligations of each party and that the VISA Member, Woodforest National Bank, is the ultimate authority should the Merchant have any problems.
Print Name*
Title*
Date

MonthDayYear
Date
V. MERCHANT SITE SURVEY (TO BE COMPLETED BY SALES REPRESENTATIVE)
Legal Business Name:
Merchant Location:

Store FrontWarehouseOtherCommercial
Merchant Location:

Office BuildingOwnedLeased
Permanent Signage?

Yes
Permanent Signage?

No
Office Building

Website (DOMAIN REQUIRED)ResidenceIndustrialResidential
Is Business Legitimate?

Yes
Is Business Legitimate?

No
Inventory Consistent with Business?

YesNo
If leased, Landlord Name:
Landlord Phone:
Landlord Phone:

I hereby certify that I have conducted my review of this merchant to the best of my ability and that, to the best of my knowledge and belief, the information set forth in this Application is true and accurate.
Inspected By (Print name)
Date

MonthDayYear
Date
Banking Information for Debits (for example: Fees)

Same as Bank Account #1
IV. Banking Information for Credits & Debits (for example: Deposits & Fees) & Tax Identification
Bank Name:*
Bank Type:*

CheckingSavingsGeneral Ledger
Bank Account #1 (DDA): (attach copy of voided check)*
Bank Routing #1 (ABA):*
Upload a copy of voided check

Browse Files

Cancelof
Federal Tax ID Number (as it appears on your income tax return)*
V. OWNERS/OFFICERS (MUST REFLECT OWNERSHIP OF 25% OR MORE)

Ownership: Each individual who directly or indirectly owns 25% or more of equity interest of the within named legal entity.
Owner 1
Name*
Title*
Residence Address, City, State, Zip*
Cell Phone Number*
Ownership*
%
Social Security*
Date of Birth*

MonthDayYear
Date
Email Address*
example@example.com
Discount Method:

DailyMonthlyStandard (1 Day Hold)Alternate Funding (Subject to approval)
Bank Account #2 (DDA): (attach copy of voided check)
Bank Routing #2 (ABA):
Bank Name:
VI. RATES & FEES (FOR VISA, MASTERCARD, DISCOVER AND AMERICAN EXPRESS UNLESS OTHERWISE NOTED)
Online Ordering Merchant Processing Pricing

Below are the fees associated with processing credit cards for online ordering.
Credit Rate
%
Other fees

Additional processing fees
Monthly Service Fee:
(Billed monthly)
Monthly Minimum Fee:
(Per occurrence) Account activity must meet minimum $25 per month
PCI Protection Plan:
(Billed monthly) Payment Card Industry (PCI) Standard for card data security.
Annual Customer Service Fee:
(Billed annually) Billed one year from Account Active Date.
PCI Compliance Non-Validation Fee:
(Per occurrence) Must complete yearly survey to avoid Non-validation fee. Charged until completed.
Chargeback Fee:
(Per occurrence) Transaction Dispute
Retrieval/Representment Fee:
(Per occurrence) Request for paper statements/documents
Pricing Structure

Tiered PricingERR Pricing
Qualified Discount Credit Rate
American Express OptBlue
Qualified
%
AMEX Pricing Structure:

Cost Plus PricingTiered PricingERR Pricing
American Express Direct
Amex Direct SE #:
Transaction Fee:
Do you need to enter Owner 2 information?

YesNo
Owner 2
Name
Title
Ownership
Percentage
Social Security
Date of Birth

MonthDayYear
Date
Residence Address, City, State, Zip
Do you need to enter Owner 3 information?

YesNo
Cell Phone Number
Email Address
example@example.com
Owner 3
Name
Title
Ownership
Percentage
Social Security
Date of Birth

MonthDayYear
Date
Residence Address, City, State, Zip
Cell Phone Number
Email Address
example@example.com
Do you need to enter Owner 4 information?

YesNo
Owner 4
Name
Title
Ownership
Percentage
Social Security
Residence Address, City, State, Zip
Date of Birth

MonthDayYear
Date
Cell Phone Number
Email Address
example@example.com
Print Name
Title
Date

MonthDayYear
Date
Legal Name (as it appears on your income tax return)
Print Authorized Signer #1 Name
Title
Date

MonthDayYear
Date
Print Authorized Signer #2 Name
Title
Date

MonthDayYear
Date
Print Authorized Signer #3 Name
Title
Date

MonthDayYear
Date
Print Authorized Signer #4 Name
Title
Date

MonthDayYear
Date
Guarantor #1 Name
Date

MonthDayYear
Date
Guarantor #2 Name
Date

MonthDayYear
Date
Should be Empty:

Required New Application

MERCHANT PAYMENT CARD APPLICATION/AGREEMENT

Woodforest National Bank

MERCHANT INFORMATION

CORPORATE ADDRESS

PHYSICAL ADDRESS

Equipment Deployment/Ordering

Percent of Business (MUST = 100%)

Sales Method (MUST = 100%)

Owner 1

Online Ordering Merchant Processing Pricing

Other fees

American Express OptBlue

American Express Direct

Owner 2

Owner 3

Owner 4