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    Logged In Office#:
EQUIPMENT INFORMATION                    Software Name:                  Other:
TERMINAL PROGRAM
 
MERCHANT TYPE   
VISA/MASTERCARD SALES PROFILE                  
 
EXISTING MERCHANT NUMBERS Apply for AMEX? American Express Discover Card Diners Club JCB Apply for Discover? If Yes, Estimated Average Ticket:   Estimated Monthly Volume: If Yes, Estimated Average Ticket: Estimated Monthly Volume:
BUSINESS NAME(S) Corporate Name (if corporation): DBA (Doing Business As) Name: Location/Site Address: City, State, Zip Contact Name/Statement mailing Address (if different than Location Site Address): City, State, Zip Federal Tax ID Number: Phone Number: Fax Number:
 

Type of Ownership:   

Type of Business (Description of Goods/Services Sold):  
No. of Years In Business:  

  
  

Have you ever accepted Visa/Mastercard?
%
(If Yes, you must submit current 3 months statements.)
Has this business or any listed Owners or Officers associated with Visa/MasterCard merchant processing been terminated?

%

  Season Sales?
If so, check High Volume Months:

MERCHANT PROFILE SECTION  




Credit Cards Swiped: Credit Cards Keyed*: Total: 100%  















COMPLETE THIS SECTION What percentage of sales are to: Individual Consumer: Business Consumer: % % Method of Marketing: Percentage of Products Sold via: Expration Date % Mail/Fax % Internet % Other % Who Processes the Order?   Who Enters credit card information into the processing system?   If credit card information is taken over the Internet, is the payment channel encrypted by SSL or better?   If merchant is an e-commerce merchant, is a merchant certificate utilized ?   If Yes, please provide the following: Merchant Certificate # Certificate Issuer Is certificate   Do you own the Product/Inventory?   Is the product stored at your business location?   If No, where is it stored? After charge authorization, how long until the product ships? days Who Enters credit card information into the processing system?   Who ships the product?   Product shipped by:   Delivery Receipt requested?   Telephone
 































ACH BANK INFORMATION Bank Name   Bank Phone Transit# (ABA Routing) Account# (DDA) LISTED OWNER(S) OR OFFICER(s) MUST SIGN AGREEMENT AND PERSONAL GUARANTEE First Name Last Name Residential Address Zip City State 1 Social Security # Home Phone % Equity Ownership Drivers License #  
How Long? Yrs Months State


Note: Voiced check must be pre-printed. Temporary checks without preprinted data myst be accompanied with a bank letter stating the account holder name, routing transit number and account number.












First Name --------------------------------------------------------------------------------------------------------------------------------------------------------- Last Name Residential Address Zip City State 2 Social Security #   Home Phone % Equity Ownership Drivers License #
How Long? Yrs Months State




---------------------------------------------------------------------------------------------------------------------------------------------------------  
Web Site URL:   E-Mail Address:

  SITE INSPECTION   I, (type name) my place of business conforms with statements on this application and is suitably equipped to do business as represented on this application.   (mm/dd/yyyy) certify that on this date






































     VISA/MASTERCARD RISK EVALUATION    Monthly Visa/Mastercard Sales Volume: $ Each applicant certifies that the above average ticket size and monthly sales volume are accurate and acknowledge that any significant variance from this information could result in delay or withheld settlement of funds and/or assessment of additional fees. Upon request, merchant must supply information to substantiate the delivery of goods and/or services and/or acknowledgement of the customer's satisfaction. Average Ticket Size for Visa/Mastercard Only: $
 


























SCHEDULE OF PROCESSING CHARGES   MO/TO and Internet                                 Visa/Mastercard Qualified Discount Rate_____________________ %     Authorization/Return Fee (per Attempt)___________________$    Monthly Statement Fee (Per Month)_______________________$               Monthly Internet Gateway Fee (Per Month)________________$                               













AMEX/Discover Auth Fee (Per Tran)_______________________$   

   










  

    
  
You must agree to the terms and conditions to submit your application.                          
       
        
 
If you agree to the terms and conditions, check here:   


TERMS AND CONDITIONS  

Chargeback(each): $    
 


ALL TRANSACTION MUST HAVE AN IMPRINT OF CARD. BY SIGNING THE MERCHANT APPLICATION AND AGREEMENT, THE OWNERS OR MANAGING MEMBERS ON THIS APPLICATION:
1. CERTIFY THAT ALL INFORMATION STATED HEREIN, INCLUDING ANY SUPPORTING DOCUMENTATION PRESENTED IN CONNECTION WITH THIS APPLICATION NEEDED FOR APPROVAL OF A MERCHANT PROCESSING AGREEMENT WITH MERRICK BANK (“BANK”), ARE TRUE AND ACCURATE;AND
2. AUTHORIZE BANK OR CLEARCHOICE MERCHANT SERVICES TO (1) RUN CREDIT REPORTS ON OWNERS/OFFICERS AND/OR GUARANTOR’S FOR APPLICATION UNDERWRITING AND APPROVAL, AND AT ANY TIME WHILE MERCHANT IS PROCESSING WITH BANK; AND
3. AUTHORIZIES ITS BANKING RELEATIONSHIPS LISTED ABOVE, AND SUPPLIERS IF REQUESTED BY BANK, TO PROVIDE INFORMATION TO THE BANK AT ANY TIME WHILE MERCHANT PROCESSING AGREEMENT REMAINS IN EFFECT, AND MERCHANT AGREES TO HOLD ITS BANK AND SUPPLIERS HARMLESS FROM ANY LIABLITY AS TO THE USE OF INFORMATION PROVIDED TO BANK;AND
4. ACKNOWLEDGES RECEIPT OF THE MERCHANT PROCESSING AGREEMENT, AND AGREES TO ABIDE BY THE TERMS AND CONDITIONS SET FOURTH IN THE MERCHANT PROCESSING AGREEMENT.
THE UNDERSIGNED, JOINTLY AND SEVERELY (IF MORE THAN ONE OWNER/OFFICER OR MANAGING MEMBER), GUARANTEES TO BANK AND CLEARCHOICE MERCHANT SERVICES THE PERFORMANCE OF THIS MERCHANT PROCESSING AGREEMENT, AND ANY AMENDMENTS THERETO PROVIDED BY MERCHANT, INCLUDING PAYMENT OF ALL SUMS DUE AND OWING AND ANY ATTORNEY FEES AND COSTS ASSOCIATED WITH ENFORCEMENT OF THE TERMS THEREOF. BANK OR CLEARCHOICE MERCHANT SERVICES SHALL NOT BE REQUIRED TO FIRST PROCEED AGAINST MERCHANT OR ENFORCE ANY OTHER REMEDY BEFORE PROCEEDING AGAINST THE UNDERSIGNED GUARANTOR. MERCHANT ACKNOWLEDGES THIS IS A CONTINUING GUARANTY AND SHALL NOT BE DISCHARGED OR AFFECTED BY THE DEATH OF THE UNDERSIGNED GUARANTOR, AND SHALL BIND THE HEIRS, ADMINISTRATORS, REPRESENTATIVES AND ASSIGNS AND MAY BE ENFORCED BY THE BENEFACTOR OF ANY SUCCESSOR TO BANK OR CLEARCHOICE MERCHANT SERVICES. THE TERMS OF THIS GUARANTY SHALL BE FOR THE DURATION OF THIS MERCHANT PROCESSING AGREEMENT AND ANY AMENDMENTS OR ADDENDUMS THERETO AND SHALL GUARANTY ALL OBLIGATIONS WHICH MAY ARISE OR ACCURE DURING THE TERM THEREFORE THROUGH ADDITIONAL TIME REQUIRED FOR THE ENFORCEMENT SUBSEQUENT TO ANY TERMINATION.

MidQualified Fee = Qualified Fee + 0.50%; NonQualified Fee = Qualified Fee + 1.75%      
 
          Complicance: $       

Request for Copy(each): $ ACH Returned Item(each): $ Checking Acct Change(each): $
Online View(monthly): $ FDR Help(each): $ Voice Auth(each): $ Batch Closure(each): $              




  Merchant Application and Agreement
   
 
Agent #: