Download Business to Business / Internet Information

Merchant Processing Application and Agreement
Blackstone1310
Blackstone1310(ia)
Sales Office_______________________________________ Print Sales Rep Name____________________________________________________________________ Sales ID#___________________________________
Merchant Number_ _________________________________ Sales Rep Signature_ ____________________________________________________________________ Phone#_____________________________________
1. Business Information
Client’s Business Name (Doing Business As):
Client’s Corporate/Legal Name (Use Also For Headquarter’s Information):
Business Address:
Billing Address (If Different Than Location Address):
City:
State:
Location Phone #:
Zip:
City:
Location Fax:
State:
Contact Name:
Business E-mail Address:
Contact Fax # / E-mail Address:
Business Website Address:
Contact Phone #:
Customer Service Ph #
Zip:
Customer Service E-Mail Address:
Send Retrieval Requests to:
o Business Location
o Corp/Legal Location
Send Merchant Monthly Statement to:
o Business Location
o Corp/Legal Location
o Individual/Sole Proprietorship: State in which Certificate of
o Tax Exempt Organization (501C) State:_______________
o Government (Federal, State, Local)
Assumed name filed:_________________________________ State:________
o International Organization
o Limited Liability Company
Location Filed:________________________________________
State Filed:__________________________
o Association/Estate/Trust State Filed_______________
o Partnership State Filed:__________
o Corporation – Chapter S, C
State:
o Medical or Legal Corporation
State:
Name (as it appears on your income tax return):
Federal Tax ID #
(as it appears on your income tax return)
o I certify that I am a foreign enity/
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 section 36.3 of your Program Guide for further information.)
SIC/MCC:
Detailed Explanation of Type of Merchandise, Products or Services Sold:
2. Additional Credit / Site Surve y Information - All Merchants
Are you using a vendor? o Yes o No If yes please supply a copy of Vendor’s report.
1. Zone:
o Business District
2. Location:
o Mall
o Mixed
o Industrial
o Office
o Home
o Apartment o Isolated
o Residential
o Shopping Area
15.Your Previous Processor:________________________________________________________________________
16.Check Reason For Leaving:
o Rate o Service
o Terminated Date:
o Other:_ __________________________________
Mail/Telephone Order/ Business to Business / Internet Information
3. How many employees:_______________________
(All questions must be answered)
4. How many registers / terminals:_______________
5. Is proper license visible? o Yes
No,explain:_________________________________________________________________
o Ground Floor
8. # Of Floors/Levels:
o 1 o 2-4 o 5-10 o 11+
9. Remaining Floor(s) Occupied by:
o Residential o Commercial
Business to Business________%
Business to Business________%
o Other:___________________________
o Full Refund
o 2,001 plus
o Exchange Only
+
Business to Consumer________%
= 100% (total sales)
4. MC / Visa / Discover® Network / American Express OnePoint sales are deposited (check one):
o Other (specify)_ ______________________________________
Name:_ _____________________________________________________________________________________
Address:_ ___________________________________________________________________________________
o None
City/State/Zip:________________________________________ Phone:________________________________
13.Do you have a refund policy for MC/Visa/Discover® Network/American Express
OnePoint Sales? o Yes o No If yes, check one.
o Exchange
o Store Credit o MC/Visa/Discover® Network Credit
o American Express OnePoint Credit?
If MC/Visa and Discover® Network Credit, within how many days do
you submit credit transactions?
o 0-3 o 4-7 o 8-14 o Over 14
14.Advertising Method (Attach at least one):
o Catalog
o Brochure
o Direct Mail
o Internet
o Phone
o Newspaper/Journals
o Date of delivery
5. Who performs product / service fulfillment? o Direct o Vendor o Other If vendor, add
11.Are customers required to leave a deposit?
o No
o Yes
If Yes, % of deposit required:_______ %
12.Return Policy:
= 100% (total sales)
0-7 days_______% + 8-14 days_______% + 15-30 days______% + over 30 days ______% = 100%
o Combination
o 501-2,000
Business to Consumer________%
3. What is the time frame from transaction to delivery? (% of orders delivered in):
o Date of order
10.Approximate Square Footage:
o 0-250 o 251-500
+
2. What % of bankcard sales represent business to business (vs business to consumer):
6. Where is the merchant name displayed at the site?
o Window
o Door
o Store Front
7. Merchant Occupies:
1. What % of total sales represent business to business (vs business to consumer):
o TV/Radio
o Other
Marketing Materials required for Mail Order, B to B, Internet over $1 Million in annual volume.
Attach Web Page for Internet Merchant.
Please describe how the transaction works, from order taking to merchant fulfillment
(attach additional sheet if necessary):
6. Does any of your cardholder billing involve automatic renewals or recurring transactions
(i.e. cardholder authorizes initial sale only)?
o Yes o No
DBA Name:____________________________________________________________________________________________ Merchant #:____________________________________________ 3. Company History
Blackstone1310
Date Business Started:
Prior Bankruptcies?
o No
o Yes
o Business and / or
Trade Reference 1
o Personal
Trade Reference 2
Vendor Name:
Vendor Name:
Address:
Address:
City:
Page 2 of 3
Blackstone1310(ia)
State:
Zip:
City:
Contact Name:
State:
Zip:
Contact Phone #:
Customer Service Ph #
Contact Telephone #:
Vendor Acct. #:
Vendor Acct. #:
4. Owner / Partner / officer
Owner / Partner / officer 1
Owner / Partner / officer 2
Name: (First, Mi, Last)
% Ownership
Name: (First, Mi, Last)
% Ownership
Title:
Title:
Home Address: (No P.O. Box)
Home Address: (No P.O. Box)
City
State:
Zip:
Telephone #:
Country:
Social Security #:
D.O.B.:
City:
State:
Zip:
Telephone #:
DL #:
State:
Country:
Social Security #:
D.O.B.:
DL #:
State:
5. Set tlement Information
Deposit Bank:
Bank Contract #:
Transit / ABA #:
Deposit Account #:
ACH Detail Flag:
o Individual
o Combined
o Separate (defaults to combined if option not selected)
6. Equipment/third part y information
Network (Front End):
o Omaha
o North
o Nashville
Do you use any third party to store process or transmit cardholder data?
o BuyPass
o Yes
o No
If yes, give name/address:___________________________________________________________________________________________________________________________________________
Please identity any Software used for storing, transmitting, or processing Card Transactions or Authorization Requests:_________________________________________________________________
Internet Gateway:
o Blackstone Gateway
Other:_________________________________________________ PC/Internet Software__________________________________________________ Quantity_ ______ $_ _________________ Terminal Model o VX510/Dual o i7910 o Other_______________________________
o Purchase
o Lease
o Reprogram
Quantity_ ______ $__________________ o Purchase
o Lease
o Reprogram
o Lease
o Reprogram
PIN Pad_ ___________________________________________________________ Quantity_ ______
Lease Company: (04) First Data Global Leasing
$__________________ o Purchase
Lease Term:______ Mos.Annual Tax Handling Fee: 10.20
Total Monthly Lease Charge: $____________ 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.
Address:
City:
State:
Zip:
Attention:
7. Grid Information - Internal Use only
Authorization Grid ID#_________________________________
Tiered Discount Grid#_ ________________________________
User Defined Grid#____________________________________
8. Tr ansaction information
Where is Sale Transacted?
Financial Data
Gross Yearly Sales Vol. (Cash + Credit + Debit + Check)
$_ ______________
Average Yearly MC/Visa Volume
$_ ______________
Average MC/Visa/Discover ® Network Ticket
$_______________
Avg. Discover ® Network Ticket
$_______________
(Estimate if Never Processed in Past)
(Must = 100%)
Store Front/Swiped
_________________ %
Internet
_________________ %
Average Yearly Discover ® Network Volume
$_ ______________
Avg. American Express Ticket
$_______________
Mail Order
_________________ %
Average Yearly American Express Volume
$_ ______________
Highest Ticket Amount
$_______________
Telephone Order
_________________ %
Seasonal? o No
o Yes
High Volume Months Open:_______________________________________________________________________________________ Total
100 %
_________________
DBA Name:____________________________________________________________________________________________ Merchant #:____________________________________________ Page 3 of 3
9. Service fee Schedule
Blackstone1310
Blackstone1310(ia)
Authorization & Capture Transaction Fees
Voice Authorization Fee
MasterCard, Visa and Discover Network Authorization & Capture Fee: $___________ (Per Item)
$1.00 (Per Item)
American Express ESA/Pass Through Authorization:
$___________ (Per Item)
JCB Authorization
$_____________(Per Item)
Electronic AVS Fee
$0.05 (Per Item)
Other Item:
$___________ (Per Item)
Other Item:
$_____________(Per Item)
Voice AVS Fee
$2.50 (Per Item)
ARU Fee
$0.75 (Per Item)
SE #___________________________________
SE#__________________________________________________________________
Miscellaneous Fees
 Dues & Assessments

Setup Fee:
o ACH
EBT-Food Stamps
Chargeback Fee $__15.00
_____(Per Item)
o Check
$________________
10.00 (Per Item)
Retrieval Fee (12B Letter) $_______
Batch Fee
Visa Processing Fees
Return Trans Fee $________ (Per Item)
$_________________ (Per Item)
$_ ________(Per Item) #:_ ____________________
Pass Visa ACQ ISA Fee:
Pass Visa Acquirer Processing Fee.
Pass Visa Misuse of Authorization Fee.
Pass Zero Floor Limit Fee.
Pass Visa International Acquirer Fee
Monthly Fees
EBT-Cash Benefits
Annual Fee:
$_______________
$_ ________(Per Item) #:_ ____________________
MasterCard Processing Fees
Pass MC Acquirer Support Fee.
Pass MC Cross Border Fee.
Pass MC National Acquirer
Brand Usage (NABU) Fee.
Discover Processing Fees
Pass Discover International Processing Fee.
o Yes o No
%
o Pass Through Debit Network Fees
MC/Visa Discover Network Mid-Qual Credit
%
Other Item Rate
$_______________ (per item)
MC/Visa Discover Network Non-Qual Credit
%
Other Volume Percent
______________ % (per item)
MC/Visa Discover Network Qual Debit
%
MC/Visa Discover Network Mid-Qual Debit
%
MC/Visa Discover Network Non-Qual Debit
%
Discount
n Pass Through Interchange
Includes Dues and Assessments
Plus Discount
Non-Qual Fees
(Based on Gross Sales Vol.)
MC/VIsa/Discover Qual Credit
%
%
MC/Visa/Discover Qual Credit
%
MC/Visa/Discover Qual Debit
%
%
MC/Visa/Discover Qual Debit
%
Blackstone1310
$________
Debit Access Fee
$________
Monthly Statement Fee
$________
Monthly Minimum Fee
$________
Gateway Fee
$________
Wright Express Other Item Rate $_ _______ (per item)
Voyager
Qual_________ % Other Item Rate $________ (per item)
MC/Visa Discover Network Qual Credit
n ERR
$________
Customer Service Fee
Fleet
PIN Debit
PIN Debit
$________
eMerchant View Access Fee
Other:______________________ $________
n Tiered Discount Fees (Based on Gross Sales Volume)
Discount
Wireless Fee
TeleCheck
o Split Dial
o License #
o MICR
o Warranty
o ECA
SE Number ___ ___ ___ ___ ___ ___ ___ ___
o No
TeleCheck Rates & Fees o Yes
Inquiry Rate
____.___%
0.10 %
December Risk Surcharge
_______
Per TXN Fee
$_________
25.00
Monthly Minimum Fee (Per Location)
$_________
5.00
ACH Processing Fee
$_________
2.50
Client Requested Operator Call (CROC)
$_________
5.00
ECA Chargeback Fee
$_________
(Only charged when entitled with TeleCheck)
10. Signature (S)
Blackstone1310(ia)
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 (Version Blackstone1310) and Confirmation Page, which is part of this Merchant Processing Application (consisting of
Sections 1-10), and by this reference incorporated herein. 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 8, 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 Equipment Lease Agreement as Section 33, if selected, the undersigned Client being the “Lessee”
for purposes of such Equipment Lease Agreement. Client authorizes Blackstone Merchant Services, Inc. and Wells Fargo Bank, N.A.(“Bank”) and their Affiliates to investigate the references, statements and other data contained herein and to obtain additional information from credit bureaus
and other lawful sources, including persons and companies names in this Merchant Processing Application. Client authorizes Blackstone Merchant Services, Inc. and BANK and their Affiliates (a) to procure information from any consumer reporting agency bearing his/her personal credit
worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living, and (b) to contact all previous employers, personal references and educational institutions. Each of the undersigned authorizes us and our Affiliates to provide amongst
each other the information contained in this Merchant Processing Application and Agreement and any information received from all references, including banks and consumer reporting agencies. It is our policy to obtain certain information in order to verify your identity while processing
your account application.
By signing below, I represent that I have read and am authorized to sign and submit this application for the above entity which agrees to be bound by the American Express® Card Acceptance Agreement (“Agreement”), and that all information provided herein is true, complete, and accurate.
I authorize Blackstone Merchant Services, Inc. and American Express Travel Related Services Company, Inc. (“AXP”) and AXP’s agents and affiliates to verify the information in this application and receive and exchange information about me personally, including by requesting reports from
consumer reporting agencies, and disclose such information to their agent, subcontractors, affiliates and other parties for any purpose permit by law. I authorize and direct Blackstone Merchant Services, Inc. and AXP and AXP agents and affiliates to inform me directly, or through the entity
above, of reports about me that they have requested from consumer reporting agencies. Such information will include the name and address of the agency furnishing the report. I also authorize AXP to use the reports from consumer reporting agencies for marketing and administrative
purposes. I understand that upon AXP’s approval of the application, the entity will be the Agreement and materials welcoming it, either to AXP’s program for Blackstone Merchant Services, Inc. to perform services for AXP or in AXP’s standard Card acceptance program, which has different
servicing terms (e.g., different speeds of pay). I understand that if the entity does not qualify for the Blackstone Merchant Services, Inc. servicing program, the entity may be enrolled in AXP’s standard Card acceptance program, and the entity may terminate the agreement. By accepting
the American Express Card for the purchase of goods and/or services, or other wise indicating its intention to be bound, the entity agrees to be bound by the Agreement.
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 Unlawful Internet Gambling Enforcement Act, 31 U.S.C. Section 5361 et seq, as may be amended from time to time. Client
agrees to all the terms of this Merchant Processing Application and Agreement. This Merchant Processing Application and Agreement shall not take effect until Client has been approved and this Agreement has been accepted by Blackstone Merchant Services, Inc and Bank.
Client’s Business Principal/Officer:
Signature X__________________________________________________________ Title ________________________________ Print Name of Signer _ _________________________________ Date _ __________
Signature X__________________________________________________________ Title ________________________________ Print Name of Signer _ _________________________________ Date _ __________
Signature X__________________________________________________________ Title ________________________________ Print Name of Signer _ _________________________________ Date _ __________
Personal Guarantee: The undersigned guarantees to Blackstone Merchant Services, Inc. and Bank the performance of this Agreement and First Data Lease, if applicable, and any addendum thereto by Client, and in the event of default, hereby waives Notice
of Default and agrees to indemnify the other parties, including payment of all sums due and owing and costs associated with enforcement of the terms thereof. Blackstone Merchant Services, Inc. and Bank shall not be required to first proceed against Client or enforce
any other remedy before proceeding against the undersigned individual. This is a continuing guarantee and shall not be discharged or affected by the death of the undersigned and shall bind the heirs, administrators, representatives and assigns and be enforced by
or for the benefit of any successor of Blackstone Merchant Services, Inc. and Bank. The term of this guarantee shall be for the duration of the Merchant Processing Application and Agreement and First Data Lease, if applicable and any addendum thereto, and shall
guarantee all obligations which may arise or occur in connection with my activities during the term thereof through enforcement shall be sought subsequent to any termination.
Personal Guarantee
Signature X ____________________________________________________________________ Print Name:____________________________________________________________ Date_________________
Personal Guarantee
Signature X ____________________________________________________________________ Accepted By Blackstone Merchant Services, Inc.
Print Name:____________________________________________________________ Date_________________
Wells Fargo Bank, N.A., Walnut Creek, CA 94598
Personal Guarantee
Signature X____________________________________________________________________ Signature X___________________________________________________________
Title_ ____________________________________________________ Date_________________ Title_________________________________________________________________ Date_________________
Blackstone1310
CONFIRMATION PAGE
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 are assessed on transactions that qualify for cer- 6. We have assumed certain risks by agreeing to provide you with Card
processing. Accordingly, we may take certain actions to mitigate our risk,
tain reduced interchange rates imposed by MasterCard, Visa and Discover
including termination of the Agreement, and/or hold monies otherwise
Network. Any transactions that fail to qualify for these reduced rates will
payable to you (see Section 23, Term; Events of Default and Section 24,
be charged an additional fee (see Section 18 of the Program Guide).
Reserve Account; Security Interest).
2. We may debit your bank account from time to time for amounts owed
7.
By
executing this Agreement with us you are authorizing us and our
to us under the Agreement.
Affiliate to obtain financial and credit information regarding your business
3. There are many reasons why a Chargeback may occur. When they occur
and the signer and guarantors of the Agreement until all your obligations
we will debit your settlement funds or settlement account. For a more deto us and our Affiliate are satisfied.
tailed discussion regarding Chargebacks, see Section 10.
8. The Agreement contains a provision that in the event you terminate
4. If you dispute any charge or funding, you must notify us within 60
the Agreement early, you may be responsible for the payment of early
days of the date of the statement where the charge or funding appears or
termination fees as set forth in Section 36, Additional Fee Information.
should have appeared.
9. If you lease equipment from Processor, it is important that you review
5. The Agreement limits our liability to you. For a detailed description
Section 34 in Third Party Agreements. This lease is a non-cancelable
of the limitation of liability see Section 20.
lease for the full term indicated.
10. Card Organization Disclosure
Visa and MasterCard Member Bank Information: Wells Fargo Bank, N.A.
The Bank’s mailing address is 1200 Montego Way, Walnut Creek, CA 94598, and its phone number is (925) 746-4143.
Important Member Bank Responsibilities:
Important Merchant Responsibilities:
a) The Bank is the only entity approved to extend acceptance of
Visa and MasterCard products directly to a Merchant.
a) Ensure compliance with cardholder data security and storage
requirements.
b) The Bank must be a principal (signer) to the Merchant Agreement.
b) Maintain fraud and chargebacks below Card Organization
thresholds.
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.
c) Review and understand the terms of the Merchant Agreement.
d) Comply with Card Organization rules.
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.
Print Client’s Business Legal Name: _________________________________________________________________________________________________
By its signature below, Client acknowledges that it received (either in person, by facsimile, or by electronic transmission) the complete
Program Guide (Version Blackstone1310) consisting of 34 pages (including this confirmation).
Client further acknowledges reading and agreeing to all terms in the Program Guide, which shall be incorporated into Client’s Agreement.
Upon receipt of a signed facsimile or original of this Confirmation Page by us, Client’s Application will be processed.
Client understands that a copy of the Program Guide is also available for downloading from the Internet at:
www.blackstoneonline.com
NO ALTERATIONS OR STRIKE-OUTS TO THE PROGRAM GUIDE WILL BE ACCEPTED AND, IF MADE, ANY SUCH ALTERATIONS
OR STRIKE-OUTS SHALL NOT APPLY.
Client’s Business Principal:
Signature (Please sign below):
X___________________________________________________________________________ ____________________________________________________ _____________________________________________________________________
Please Print Name of Signer
Blackstone1310
Title
__________________________
Date
Terminal Setup Form
Merchant DBA
Blk MID
Terminal Information
Your Answers
Terminal Model (e.g., Vx510, Vx510/LE, Vx510/IP, Vx570, i5100 PCI, FD200, etc.)
Besides this, How many terminals does the merchant have with this processor MID? (#)
Will there be Multiple MID’s in this terminal? (Yes/No)
For High Speed and Wireless units, indicate the “Serial Number” (If unit is not in Blackstone)
For Wireless Terminals, indicate the “SIM Card Number” (If unit is not in Blackstone)
Is this a New Deployment, Transfer or Reprogramming?
General Parameters - I
Yes
No
Tips / Servers
Yes
No
External Pin Pad?


Tips Processing?


Debit Processing?


Ask for Tip during the sale?


EBT Processing?


Allow closing with Unadjusted Tips?


Fraud Control?


Print a receipt after each Tip Adjustment?


Ask for Cashier, Server or Employee Number?
Ask for Invoice Number during the sale?


Ask for Customer Code during the sale?




Fill if “Yes”
Yes
No
Ask Password For...
Yes
No
Auto Close (Time?)


Sales


Debit Cash Back (Maximum?)


Returns


EBT Cash Back (Maximum?)


Voids


Apply Tax on sale (Percent?)


Settlements (Closing)




Receipt Reprints




Reports Menu




EBT Balance Inquiry




Batch Review




Authorization Transactions


Communication Parameters (Dialup Terminals)
Yes
No
Is this terminal going to be connected to a Phone Line? If “Yes”, indicate PBX (e.g., 9, 0, None.)


Communication Parameters (High Speed Terminals)
Password?
PBX?
IP Addresses
Dynamic

Static
For Static Networks, indicate the “IP Address”
For Static Networks, indicate the “Subnet Mask”
For Static Networks, indicate the “Default Gateway”
For Static Networks, indicate the “Primary DNS Server”
For Static Networks, indicate the “Secondary DNS Server”
Note: For Firewalls and Routers, the following ports are required to be open: From 19000 to 19999 + Port 443
Other Requirements
Blackstone Representative
Name:
______________________________________
Signature
blackstonemerchant.com


Note: Auto-Close is not recommended with Tips Processing
General Parameters - I
Please select the “Network Type”


