Download MERCHANT PROCESSING APPLICATION AND AGREEMENT

Blackstone1209
M e r c h a n t P r o c e s s i n g App l i c at i o n a n d A g r e e m e n t
Blackstone1302
Sales Office_______________________________________ Print Sales Rep Name___________________________________________________________________ Sales ID __________________________________
Merchant Number_ _________________________________ Sales Rep. Signature_ ___________________________________________________________________ Phone #___________________________________
Page 1 of 3
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 #:
–
)
(
Business E-mail or Website Address:
Send Retrieval Requests to:
Contact Name:
Contact Phone #:
Contact Phone #:
–
)
 Business Location
Zip:
–
)
(
State:
(
Assumed Name Filed:_ ____________________________________ State:__________
–
Send Merchant Monthly Statement to:
 Corp/Legal Location
 Individual/sole Proprietorship: State in which Certificate of
Contact Fax# / E-mail Address:
)
 Business Location
 Corp/Legal Location
 Tax exempt organization (501C) State:_________________
 Government (Federal, State, Local)
 International organization
 Limited liability
 Corporation – chapter S, C
State:__________
Location Filed:_____________________
 Medical Or Legal Corporation
State:__________
 ASSOCIATION/ESTATE/TRUST State Filed:_________________
Company State Filed:__________
 Partnership State Filed:__________
Detailed Explanation of Type of Merchandise, Products or Services Sold:
Federal Tax Id #:
SIC/MCC:
2 . additional c redit / site survey information – all merc hants
Yes
Are you using a Vendor?
1. Zone:
No
If yes, please supply a copy of Vendor’s report
Business District Industrial
2. Location: Mall Mixed
Residential
Office
Home
Apartment Isolated
15. Your Previous Processor:___________________________________________________________________
Shopping Area
16. Check Reason For Leaving:
 Rate  Service
Terminated Date:_ _____________ Other:___________________________
3. How many employees: ______________
Mail/Telephone Order / Internet / Business to Business Information
4. How many registers / terminals: ______________
5. Is proper license visible? Yes
No, explain: ____________________________________________________
Business to Business _______%
6. Where is the merchant name displayed at the site?
Window
Door
Store Front
7. Merchant Occupies: Ground Floor
8. # of Floors/Levels:
1
Other:
+ Business to Consumer _______%
= 100% (total sales)
4. MC / Visa / Discover Network sales are deposited (check one):
 Date of order
11. Are customers required to leave a deposit?
No
Yes
If Yes, % of deposit required:_______%
 Other (specify):________________________________________
Direct
Vendor
Other
If vendor, add
Name:_ ___________________________________________________________________________________
None
If MC/Visa and Discover Network Credit, within how many days do
you submit credit transactions? 0-3 4-7 8-14  Over 14
14. Advertising Method (Attach at least one):
Catalog
Brochure Direct Mail
Internet
Phone Newspaper/Journals
 Date of delivery
5. Who performs product / service fulfillment?
13. Do you have a refund policy for MC/Visa/Discover® Network Sales?
Yes
No If yes, check one.
Exchange
Store Credit_________ MC/Visa/Discover Network Credit
Business to Business _______%
0-7 days______% + 8-14 days______% + 15-30 days______% + over 30 days______% = 100%
 Combination
Exchange Only
= 100% (total sales)
3. What is the time frame from transaction to delivery? (% of orders delivered in):
10. Approximate Square Footage:
 0-250  251-500  501-2,000  2,001 plus
12. Return Policy: Full Refund
+ Business to Consumer _______%
2. What % of bankcard sales represent business to business (vs business to consumer)
____________________
 2-4  5-10  11 +
9. Remaining Floor(s) Occupied by:
 Residential  Commercial
(All Questions must be Answered)
1. What % of total sales represent business to business (vs business to consumer):
Address:_ _________________________________________________________________________________
City/State/Zip:_____________________________________ Phone:___________________________________
Please describe how the transaction works, from order taking to merchant fulfillment
(attach additional sheet if necessary):
_ ________________________________________________________________________________________
TV/Radio
Other
_ ________________________________________________________________________________________
_ ________________________________________________________________________________________
6. Does any of your cardholder billing involve automatic renewals or recurring transactions
(i.e. cardholder authorizes initial sale only)?
Yes
No
Marketing Materials required for Mail Order, B to B, Internet over $1 Million in annual volume.
Attach Web Page for Internet Merchant.
3. Company History
Date Business Started:
Prior Bankruptcies?
 No
 Yes
 Business and /or
Trade Reference 1
Vendor Name:
Address:
City:
Contact Name:
Contact Telephone: (
Vendor Acct. #:
 Personal
Trade Reference 2
State:
Zip:
Vendor Name:
Address:
City:
State:
Zip:
Contact Name:
)
Contact Telephone: (
)
Vendor Acct. #:
Blackstone Merchant Services is a registered ISO/MSP of Wells Fargo Bank, N.A., Walnut Creek, CA 94598
Bank Copy - White • Sales Representative Copy - Yellow • Merchant Copy - Pink
Revised 04/01/10
DBA Name:____________________________________________________________________________________________
Merchant #: _______________________________________________________________
Page 2 of 3
4 .OWNERS / PARTNERS / OFFICERS
OWNER / PARTNER / OFFICER 1
OWNER / PARTNER / OFFICER 2
% Ownership:
Name: (First, MI, Last)
Title:
% Ownership:
Name: (First, MI, Last)
Title:
Home Address: (No P.O. Box)
Home Address: (No P.O. Box)
City:
State:
Zip:
City:
Telephone #:
State:
Zip:
Telephone #:
(
)
–
Social Security #:
(
)
–
Social Security #:
D.O.B.:
DI #:
State:
D.O.B.:
DI #:
State:
5. SETTLEMENT INFORMATION
Bank Contract:
Deposit Bank:
Deposit Account #:
Transit / ABA #:
6 . EQUIPMENT/ THIRD PARTY INFORMATION
Do you use any third party to store, process or transmit cardholder data?
 Yes
 No
If yes, give name/address:_____________________________________________________________________________________________________________________________________________
Please identify any Software used for storing, transmitting, or processing Card Transactions or Authorization Requests:____________________________________________________________________
Internet Gateway:  YourPay.com
 Blackstone Gateway
 Other:__________________________
Wireless Network:______________________________
PC/Internet Software____________________________________________________
Quantity _______ 
_ Purchase $ ______
 ACH

Check
 Rent
 Lease
 Reprogram
Terminal Model_ _______________________________________________________
Quantity _______ _ Purchase $ ______
 ACH

Check
 Rent
 Lease
 Reprogram
Printer Model__________________________________________________________
Quantity _______ _ Purchase $ ______
 ACH

Check
 Rent
 Lease
 Reprogram
PIN Pad_ _____________________________________________________________
Quantity _______ _ Purchase $ ______
 ACH

Check
 Rent
 Lease
 Reprogram
Lease Company: (04) First Data Global Leasing
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
Mc Credit
Mpg Id
_____________________
Visa Credit
MPG ID
_____________________
Mc debit
Mpg Id
_____________________
Visa debit
MPG ID
_____________________
8-position Alpha/Numeric
Mc Credit
tiered grid id
_____________________
Visa Credit
_____________________
8-position Alpha/Numeric
8-position Alpha/Numeric
8-position Alpha/Numeric
8-position Alpha/Numeric
Tiered grid id
(Client Use)
Mc debit
Tiered Grid ID
_____________________
Visa debit
8-position Alpha/Numeric
Tiered Grid ID
(Client Use)
8-position Alpha/Numeric
(Client Use)
_____________________
8-position Alpha/Numeric
(Client Use)
Discover Network
Credit Mpg id
_____________________
Authorization Grid Id#:
Discover Network
debit Mpg id
_____________________ ______________________
Discover Network
Credit Tiered
Grid id
_____________________
Discover Network
debit Mpg id
Grid id
_____________________ ______________________
8-position Alpha/Numeric
8-position Alpha/Numeric
8-position Alpha/Numeric
(Client Use)
User Defined Grid Id#:
8-position Alpha/Numeric
(Client Use)
8 .TRANSACTION INFORMATION
WHERE IS SALE TRANSACTED? (Must = 100%)
FINANCIAL DATA
Gross YEARLY Sales Volume
$______________
Average MasterCard/Visa
Discover Network Volume
(Cash + Credit + Debit + Check)
$ ______________
(Estimate if Never Processed in Past)
Average YEARLY MasterCard/Visa/
Discover Network Volume
Seasonal?
No
Yes
$______________
Highest Ticket Amount
$ ______________
High Volume Months Open:_____________________________________________________________________________________
Store Front/Swiped
___________ %
Internet
___________ %
Mail Order
___________ %
Telephone Order
___________ %
Total
100 %
___________
9. SERVICE FEE SCHEDULE
Blackstone1209
Voice Authorization Fee:
MasterCard, Visa and Discover Network Authorization & Capture Fee: $______________ (Per Item)
American Express ESA/Pass Through Authorization:
Other Item SE #_______________________________________
Blackstone1302
Authorization & Capture Transaction Fees
$______________
$______________
(Per Item)
JCB Authorization $_________ (Per Item)
(Per Item)
Other Item $__________(Per Item)
SE #_______________________________________
$ 1.00 (Per Item)
Electronic AVS Fee
$ 0.05 (Per Item)
Voice AVS Fee
_
$ 2.50 (Per Item)
ARU Fee
_
$ 0.75 (Per Item)
Blackstone Merchant Services is a registered ISO/MSP of Wells Fargo Bank, N.A., Walnut Creek, CA 94598
Bank Copy - White • Sales Representative Copy - Yellow • Merchant Copy - Pink
Revised 04/01/10
DBA Name:____________________________________________________________________________________________
Merchant
9. Service Fee Schedule (Cont’d)
Page 3 of 3
Miscellaneous Fees
Monthly Fees
 Dues & Assessments Chargeback Fee $_______(Per Item)
Retrieval Fee (12B Letter)
Sales Transaction Fee $__________ (Per Item)
Batch Fee
EBT-Food Stamps
$__________ (Per Item) #:________________________
Annual
Fee: $___________
Other: _______________ $_____________
Pass ACQ ISA Fee:
 Yes  No
Minimum Monthly Fee
$________(Per Item)
Wireless Fee
eMerchantView Access Fee
Customer Service Fee
$__________ (Per Item) #:_ ____________________ Debit Access Fee
EBT-Cash Benefits
MC Acquirer
Support Fee:  Yes  No
MC Cross
Border Fee:
 Yes  No
MasterCard Acceptance
MC National Acquier
Brand Usage (NABU) Fee:  Yes  No
Monthly Statement Fee
$_______________
 Accept MC Credit transactions only
 Accept MC Non-PIN Debit transactions only
Discount Collected  Daily x Monthly
$___________
$___________
$___________
$___________
$__________ (Per Item)
Supplies:_ ____________________ $___________
Other:________________________ $___________
$__________ (Account on File)
(presumed, unless any selections below are checked)
Accept all MasterCard, Visa and Discover Network Transactions
Return Trans. Fee $_______(Per Item)
Discover Network Acceptance
Visa Acceptance
 Accept Discover Network Credit transactions only
 Accept Discover Network Non-PIN Debit transactions only
 Accept Visa Credit transactions only
 Accept Visa Non-PIN Debit transactions only
See Section 1.9 of the Program Guide for details regarding limited acceptance.
Tiered
Fleet
Wright Express
Discount Fees (Based on Gross Sales Volume)
Discount
MPG TXN Fee
Other Item Rate $____________(per item)
Voyager
MC/Visa/Discover Network Qual Credit
% $
MC/Visa/Discover Network Mid-Qual Credit
% $
Mid-Qual Credit Surcharge
%
MC/Visa/Discover Network Non-Qual Credit
% $
Non-Qual Credit Surcharge
%
MC/Visa/Discover Network Qual Dedit
% $
Qual___________ %
Other Item Rate $_ ____________ (per item)
TeleCheck
 Split Dial
 License #
SE Number
___ ___ ___ ___ ___ ___ ___ ___
 MICR
 Warranty
 ECA
MC/Visa/Discover Network Mid-Qual Dedit
% $
Mid-Qual Dedit Surcharge
%
TeleCheck Rates & Fees  Yes  No
MC/Visa/Discover Network Non-Qual Dedit
% $
Non-Qual Dedit Surcharge
%
Inquiry Rate
____.___ __%
December Risk Surcharge
.10 %
_________
Non-Qual Fees Per TXN Fee
$_ _________
ERR
Discount
Discount
Non-Qual Fees
25.00
$_ _________
Monthly Minimum Fee (Per Location)
MC Qual Credit
%
%
VIsa Qual Credit
%
%
MC Qual Dedit
%
%
Visa Qual Dedit
%
Discover Network Qual Credit
%
%
Discover Network Qual Dedit
%
% Client Requested Operator Call (CROC)
ECA Chargeback Fee
% (Only charged when entitled with TeleCheck)
5.00
$_ _________
ACH Processing Fee
2.50
$_ _________
5.00
$_ _________
 Pass Through Interchange – Includes Dues and Assessments
Discount
Other Item Rate
$__ ________
(per item)
Other Volume Percent _ __ ________%
Discount
(Based on
Gross Sales Vol.)
MC Qual Credit
%
MC Qual Dedit
%
Discount
(Based on
Gross Sales Vol.)
Visa Qual Credit
%
Visa Qual Debit
%
(Based on
Gross Sales Vol.)
%
Discover Network Qual Credit
%
Discover Network Qual Debit
PIN Debit
 Pass Through Debit Network Fees (ETC Only)
Blackstone1209
Other Item Rate
$___________ (per item)
Other Volume Percent______________ %
10. Signature (S)
Blackstone1302
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 Blackstone 1209) 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 agents 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 agents (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. 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 Ametican 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 aknowledge 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
ammended 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.
Wells Fargo Bank, N.A., Walnut Creek, CA 94598
Print Name:___________________________________________________________ Date_____________________
Signature X_ __________________________________________________________________ Signature X______________________________________
Title_____________________________________________________ Date_ _______________ Title_________________________________________________________________ Date_____________________
Blackstone Merchant Services is a registered ISO/MSP of Wells Fargo Bank, N.A., Walnut Creek, CA 94598
Bank Copy - White • Sales Representative Copy - Yellow • Merchant Copy - Pink
Revised 04/01/10
Blackstone1209
C O N F I R M AT I O N PAG E
Please read the Merchant Processing 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 certain
reduced interchange rates imposed by MasterCard, Visa and Discover Network.
Any transactions that fail to qualify for these reduced rates will be charged an
additional fee (see Section 18 of the Card Processing Program Guide).
2. We may debit your bank 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 10.
4. If you dispute any charge or funding, you must notify us within 45 days of
the date of the statement where the charge or funding appears or should have
appeared.
5. The Agreement limits our liability to you. For a detailed description of the
limitation of liability see Section 20.
6. We have assumed certain risks by agreeing to provide you with Card
processing. Accordingly, we may take certain actions to mitigate our risk, including termination of the Agreement, and/or hold monies otherwise payable to
you (see Section 23, Term; Events of Default and Section 24, Reserve Account;
Security Interest).
7. By executing this Agreement with us you are authorizing us to obtain
financial and credit information regarding your business and the signer and
guarantors of the Agreement until all your obligations to us are satisfied.
8. The Agreement contains a provision that in the event you terminate the
Agreement early, you may be responsible for the payment of early termination
fees as set forth in Section 36, Additional Fee Information.
9. If you lease equipment from Processor, it is important that you review
Section 34 in Third Party Agreements. This lease is a non-cancelable lease
for the full term indicated.
10. Association 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 Association 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 Association 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 Blackstone1209) consisting of 30 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 STRIKEOUTS SHALL NOT APPLY.
Client’s Business Principal:
Signature (Please sign below) :
X ___________________________________________________________________________
____________________________________________________
Title
________________________________________________________________________
Please Print Name of Signer
Blackstone1209
30
__________________________
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 Invoice Number during the sale?


Ask for Cashier, Server or Employee Number?
Ask for Customer Code during the sale?
General Parameters - I
Yes
No
Auto Close (Time?)


Debit Cash Back (Maximum?)


EBT Cash Back (Maximum?)

Apply Tax on sale (Percent?)




Yes
No
Sales


Returns



Voids




Settlements (Closing)




Receipt Reprints




Reports Menu




EBT Balance Inquiry




Batch Review



Authorization Transactions


Yes
No



Fill if “Yes”
Note: Auto-Close is not recommended with Tips Processing
Ask Password For...
Communication Parameters (Dialup Terminals)
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)
Please select the “Network Type”
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
Password?
