MERCHANT PROCESSING APPLICATION & AGREEMENT AUX365

MERCHANT PROCESSING APPLICATION & AGREEMENT
1. GENERAL INFORMATION | BUSINESS LOCATION INFORMATION | BUSINESS STRUCTURE
Client Business Name (Doing Business As)*
Location Address (physical location; No PO Box)*
Suite/Floor/etc
City*
State*
Zip*
DBA Phone (physical location)*
Location Fax
Customer Service Phone (if different from DBA)*
Business Website Address
Bussiness Email*
Client Corporate Name/Legal Name*
Corporate Address*
Suite/Floor/etc
City*
State*
Zip*
Contact Name*
Contact Phone*
Ext
Legal Phone (if different from contact)
Federal Tax ID*
Date Business Started

MonthDayYear
Date
Prior Security Breach?

YesNo
Send Retrieval/Chargeback Requests to:

Corporate AddressLocation Address
Multiple Locations?

YesNo
If Yes, enter # of locations
Additional Location to existing MID
Indicate Company Structure:

Sole PropPartnershipC CorpS Corp501 C/Tax ExLLC/LLPGovt. (Local/State/Federal)
State Filing
I certify that I am a foreign entity/nonresident alien (If checked, please attach IRS Form W-8)

Select
2. BANKING ACCOUNT INFORMATION
Bank Name*
Bank Phone*
Routing*
Account*
ACH Method:

CombinedIndividual
Prior Bankruptcies?

YesNo
If Yes

PersonalBusiness
Date Discharged

MonthDayYear
Date
3. MEMBER BANK DISCLOSURE

Visa and MasterCard Member Bank Information asindicated below by Processor: Central Bank of St. LouisVisa and MasterCard Member Bank Information asindicated below by Processor: FFB Bank
4. OWNERS | PARTNERS | OFFICERS
OWNER | PARTNER | OFFICER 1 | CONTROL PRONG
Name
Title
% Ownership
Home Address
Unit
City
State
Zip
Cell Phone
Social Security*
Date of Birth*

MonthDayYear
Date
Email Address
example@example.com
OWNER | PARTNER | OFFICER 2
Name
Title
% Ownership
Guarantor**

YesNo
Home Address
Unit
City
State
Zip
Cell Phone
Social Security
Date of Birth

MonthDayYear
Date
Email Address
example@example.com
5. NATURE OF BUSINESS | TRANSACTION INFORMATION
RestaurantHealthcareLodgingSupermarketGovernmentInternetQSREducationUtilitesPetroleumCharity/Non ProfitB2BMail / Telephone OrderOther
Requested Monthly V/MC/DS Card Volume
Requested Average V/MC/DS Card Ticket
Requested Highest Payment Card Ticket
American Exp Monthly Volume
American Exp Average Ticket
Card Present Swiped
Card Present Keyed
MOTO
Internet (Ecommerce)
Sales to Consumers
Sales to Business
Sales to Govt.
Months Closed
Previous Processor
Reason For Leaving
If yes, please explain the reason for termination
Description of Products or Services Sold*
Describe your Return Policy
Days to delivery*
6. SERVICE ACCEPTANCE | FEE SCHEDULES AND OTHER CARD TYPES
Request to Accept Card Types:

PIN DebitETB
Select VI/MC/Discover NetworkDiscount Plan:

QrevTired BasicFlat RatePass ThroughERR
Requested Discount Payment Method:

DailyMonthly

DISCOUNT FEES: Visa, MasterCard, Discover & PIN Debit

	Tiered/ERR %	Tiered/ERR $ Per Item
Qualified Discount =
Mid Qual = (Qual+)
Non Qual = (Qual+)
Debit Qual Discount =
Debit Mid Qual = (Qual+)
Debit Non Qual = (Qual+)

DISCOUNT FEES: Visa, MasterCard, Discover & PIN Debit

	Pass Through IC+ %	Pass Through IC+ $ Per Item
Credit
Signature Debit =
Credit =
Signature Debit = (Card Present)
Credit = (Card Not Present)
Signature Debit= (Card Not Present)
Credit Qual = (Card Present)
Credit Qual = (Card Not Present)

Authorization, Monthly AND Miscellaneous Fees

	Fees
Visa/MC/Discover Networks $
AMEX/Fleet/Other $
PIN Debit $
Monthly Service $

Next Day Funding

Select
Per Month: *NDF is subject to approval and all POS Device batch(es) must be closed 5:30pm PST/8:30pm EST for Central Bankand 7:30p PST/10:30pm EST for FFB Bank Monday - Saturday and by 3pm PST/6pm EST on Sunday. All payments are provisional and are subject to, including butnot limited to: additional fees, chargebacks, withholding, set off, security and reserve rights. Processor or Bank will not be liable for any delay in receipt of funds,fees for any delays, or errors in debit and credit entries caused by third parties, including by not limited to, any Association or your financial institution.
Terminal Features: Choose Desired Functions
Time Zone
Type of Equipment
Certification of Beneficial Owner(s)
OWNER | PARTNER | OFFICER 1 | CONTROL PRONG
Signature
Title
Print Name
Date

MonthDayYear
Date
OWNER | PARTNER | OFFICER 2
Signature
Title
Print Name
Date

MonthDayYear
Date
Personal Guarantee
Signature
Print Name
Title
Print Client’s Business Name
By its signature below, Client acknowledges that it has received (either in person, by facsimile, or by electronic transmission) the complete Program Guide including this confirmation.
Client’s Business Principal: Signature
Print Name Of Signer
Title
Date

MonthDayYear
Date
Should be Empty:

MERCHANT PROCESSING APPLICATION & AGREEMENT

OWNER | PARTNER | OFFICER 1 | CONTROL PRONG

OWNER | PARTNER | OFFICER 2

Terminal Features: Choose Desired Functions

Certification of Beneficial Owner(s)

OWNER | PARTNER | OFFICER 1 | CONTROL PRONG

OWNER | PARTNER | OFFICER 2

Personal Guarantee