Print the names and titles of whoever will sign.
These last few numbers are needed to run the application. They are encrypted as soon as you submit, and they are the only answers that are not kept if you save and come back later, so please fill them in just before you submit.
Rates. Choose the program being quoted, then fill in the rates for it. Numbers only, with no % sign. Nothing here is required.
These are the fees and the terms that apply to this application. They are the same words and the same amounts that appear on the printed application you are signing. A dash means no amount is set for that item on this application.
Early Termination Fee $ ______ The initial term of this Agreement is three years from the date of your approval by our Credit Department (the Initial Term). If you terminate this Agreement before the end of the then current term or otherwise stop processing your transactions with us, you will be charged this Early Termination Fee. After the Initial Term, subject to Part IV, Section A.3, this Agreement will automatically renew for successive 30 day periods. Merchant Initials ______
9. SIGNATURE(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 and Confirmation Page, which is part of this Merchant Processing Application (consisting of Sections 1-9), 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 this Merchant Processing Application and/or may leave a detailed voice message in the event that 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 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 stated in Section 5, Transaction Information section above, you are authorized to accept transactions in accordance with the percentages indicated in that section. This signature page also serves as a signature page to the TeleCheck Solutions Agreement appearing in the Third Party Section of the Program Guide, if selected, the undersigned Client being “You” and “Your” for the purposes of the TeleCheck Solutions Agreement. On behalf of myself as an individual, the entity on whose behalf I am signing, and its principals (collectively, the Client Parties),(A) I authorize Processor, Servicers, the applicable Payment Networks, and its and their Affiliates, third party subcontractors, service providers, and/or agents: (i) to use, disclose, and exchange amongst them and externally with other third-parties, the information in the Agreement and information about each of the Client Parties, (including by requesting and sharing, personal and business consumer reports, bank references, and other information as necessary from time to time), for marketing and administrative purposes, verification purposes, purposes under the Merchant Processing Application and Agreement (MPA), if approved, product improvement, fraud, analytics and any other purposes permitted by law (and to continue to use and share such information following the termination of this Agreement); (ii) to inform me directly about the contents of requested consumer reports (including the name and address of the agency furnishing the report), and (ii) to receive any and all personal and business credit financial information from all references, including banks and consumer reporting agencies, which are hereby released to provide that information; and (B) I certify that: (i) The federal taxpayer identification number and corresponding filing name provided herein are correct; (ii) The statements made and agreed to in this MPA, to which I have not made any alterations or stricken out any language, are true, complete and accurate, and may be relied upon as current unless changed or updated per the Notice provisions of Agreement; (iii) I can read and understand the English language; (iv) I have received and read a copy of the (a) MPA (consisting of Sections 1-9), (b) Program Guide, (c) Confirmation Page (version PPC2904), and (v) I have authority to bind the entity on whose behalf I am signing below and have the appropriate consents and authority from each of the Client Parties (whether individuals or other entities) to authorize the use and sharing of data described above. Processor’s privacy notice is available at www.fiserv.com/privacy. Client authorizes FDMS and Bank and their affiliates to debit Client’s designated bank account via Automated Clearing House (ACH) for costs associated with equipment hard ware, 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 Unlaczul 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). To help the government fight the funding of terrorism and money laundering activities, Servicers obtain, verify, and record certain information including your full name, physical address, and any other information needed for identity verification purposes while processing this MPA, as described in the USA Patriot Act. 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 will not take effect until Client has been approved and this Agreement has been accepted by Processor and Bank. Acceptance by Processor and Bank will occur upon the earlier of the execution of this Merchant Processing Application and Agreement by Processor and Bank, or the commencement of the provision of the Services by Processor and Bank.
Client’s Authorized Signer:
Personal Guarantee: In exchange for First Data Merchant Services LLC, Citizens Bank, N.A., (a member of Visa USA, Inc. and Mastercard International, Inc.), and TeleCheck Services, LLC, (the Guaranteed Parties) acceptance of the MPA, the Agreement, and/or the Equipment Agreement and/or the TeleCheck/TRS Solutions Agreement, the undersigned (Guarantor): (A) Unconditionally and irrevocably guarantees the full payment and performance of Client’s obligations (i) as they now exist or as modified under the foregoing agreements, (ii) with or without actual notice of changes, and (iii) during and after the term of the agreements; (B) Waives notice of Merchant’s default; (C) Shall indemnify the Guaranteed Parties for any and all amounts due from Client; (D) Warrants, with knowledge that Guaranteed Parties are acting in full reliance on the same, this Personal Guarantee of payment, and not of collection; (E) Acknowledges that (i) the Guaranteed Parties may proceed in law directly against Guarantor and not Client, (ii) this is a continuing personal guarantee and shall not be discharged or affected for any reason, and (iii) information about the Guarantor as one of the Client Parties may be used and shared as set forth in Section 9.
Part 1: Confirmation Page
Processor Name: First Data Merchant Services LLC Information: Address: 4000 NW 120th Avenue, Coral Springs, FL 33065
URL: merchants.fiserv.com Customer Service #: 1-800-858-1166
Please read the program guide in its entirety. It describes the terms under which we will provide merchant processing Services to you. From time to time you may have questions regarding the contents of your Agreement with Bank and/or Processor or the contents of your Agreement with TeleCheck. The following information summarizes portions of your Agreement in order to assist you in answering some of the questions we are most commonly asked.
1. Your Discount Rates and other fees and charges are calculated based on transactions qualifying for certain program pricing and interchange rates levied by the applicable Payment Network. Transactions that fail to qualify for these rates will be charged an additional fee. We will provide you with a schedule of fees and charges in connection with the Services. Interchange and program pricing levied by the Payment Network is subject to change, (see Section 25 of the General Terms & Conditions).
2. We may debit your bank account (also referred to as your Settlement Account) from time to time for amounts owed to us under the Agreement.
3. There are many reasons why a Chargeback may occur. When they occur we will debit your settlement funds or Settlement Account. For a more detailed discussion regarding Chargebacks see Section 14 of the Your Payments Acceptance Guide or see the applicable provisions of the TeleCheck Solutions Agreement.
4. In consideration of the Services provided by us, you shall be charged, and hereby agree to pay us any and all fees set forth in this Agreement (for the purpose of clarity, this includes the Application and any additional pricing supplements or subsequent communications), all of which shall be calculated and payable pursuant to the terms of this Agreement and any additional pricing supplements or subsequent communications. If you dispute any charge or funding, you must notify us within 60 days of the date of the statement where the charge or funding appears for Card Processing or within 30 days of the date of a TeleCheck transaction.
5. The Agreement limits our liability to you. For a detailed description of the limitation of liability see Section 27 and 40.11 of the Card General Terms; or Section 17 of the TeleCheck Solutions Agreement.
6. We have assumed certain risks by agreeing to provide you with Card processing or check services. Accordingly, we may take certain actions to mitigate our risk, including termination of the Agreement, and/or hold monies otherwise payable to you (see Card Processing General Terms in Section 32, Term; Events of Default and Section 33, Reserve Account; Security Interest), (see TeleCheck Solutions Agreement in Section 7), under certain circumstances.
7. By executing this Agreement with us you are authorizing us and our Affiliates to obtain financial and credit information regarding your business and the signers and guarantors of the Agreement until all your obligations to us and our Affiliates are satisfied.
8. The Agreement contains a provision that in the event you terminate the Agreement prior to the expiration of your initial 3- year term, you will be responsible for the payment of an early termination fee as set forth in Part 4, A.3 under “Additional Fee Information” and Section 6.2 of the TeleCheck Solutions Agreement.
9. For questions or concerns regarding your merchant account, contactc ustomer service at the number located on your Merchant Services Statement.
10. Payments Network Disclosure Visa and Mastercard Member Bank Information: Citizens Bank, N.A.
The Bank’s mailing address is 1 Citizens Plaza, Providence, RI 02903, and its phone number is 1-888-211-4057.
Important Member Bank Responsibilities: a) The Bank is the only entity approved to extend acceptance of Visa and Mastercard products directly to a merchant. b) The Bank must be a principal (signer) to the Agreement. c) The Bank is responsible for educating merchants on pertinent Visa and Mastercard rules with which merchants must comply; but this information may be provided to you by Processor. d) The Bank is responsible for and must provide settlement funds to the merchant. e) The Bank is responsible for all funds held in reserve that are derived from settlement. f) The Bank is the ultimate authority should a merchant have any problems with Visa or Mastercard products (however, Processor also will assist you with any such problems).
Important Merchant Responsibilities: a) Ensure compliance with Cardholder Information security and storage requirements. b) Maintain fraud and Chargebacks below Payments Network thresholds. c) Review and understand the terms of the Merchant Agreement. d) Comply with Payments Network Rules and applicable law and regulations. e) Retain a signed copy of this Disclosure Page. f) You may download Visa Regulations from Visa’s website at: https://usa.visa.com/content/dam/VCOM/download/about-visa/visa-rules- public.pdf and https://usa.visa.com/dam/VCOM/download/merchants/visa-acceptance- risk-standards.pdf (Visa Acceptance Risk Standards). g) You may download Mastercard Regulations from Mastercard’s website at: https://www.mastercard.us/content/dam/public/mastercardcom/na/global- site/documents/mastercard-rules.pdf. h) You may download American Express Merchant Operating Guide from American Express’ website at: www.americanexpress.com/us/merchant.
Print Client's Business Legal Name: ______
By its signature below, Client acknowledges that it has received the Merchant Processing Application, Program Terms and Conditions consisting of
44 pages including this Confirmation Page and the applicable Third-Party Agreement(s).
Client further acknowledges reading and agreeing to all terms in the Program Terms and Conditions. Upon receipt of a signed facsimile or original of
this Confirmation Page by us, Client’s Application will be processed. Client’s Principal Signature: (Please sign below) X Please Print Name of Signer
No alterations or strikeouts to the program terms and conditions will be accepted. Title Date
Signing. Sign with a finger or a mouse. Each box below says which lines of the application it is applied to.
Your browser does not support e-Signature field.
