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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?