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Additional_Equipment_IND_052007

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									            MSP Additional Equipment/Services                             Submit Request Using the Additional Equipment/Services Online Form                               E-mail questions to MSP Support Regional Inbox

SUBMITTED BY
TO THE BEST OF MY KNOWLEDGE, I CERTIFY THAT THE INFORMATION PROVIDED IN THIS MERCHANT APPLICATION WAS PROVIDED BY THE MERCHANT AND IS TRUE, COMPLETE AND ACCURATE.
MSP SHORT NAME:           NTC                        MSP REP #:   9159               EMAIL: service@nationaltransaction.com                                      MSP PHONE #: fx954-346-3391                     DATE:
MERCHANT INFORMATION
MID:                                          DBA NAME:                                                                          SHIP TO:      ADDRESS PROVIDED IN MERCH INFO OR PROVIDE A CONTACT NAME & ADDRESS BELOW

                                                                                                                                 SPECIAL INSTRUCTIONS:
CONTACT NAME:

ADDRESS 1:

ADDRESS 2:

CITY:                                         STATE/PROVINCE:                 ZIP:                       COUNTRY:                EMAIL ADDRESS:               (REQUIRED FOR MCP & VAR)

PLEASE NOTE: IF A REQUEST TYPE IS NOT LISTED ON THIS FORM IS IT BECAUSE (IF AVAILABLE) IT REQUIRES AN ADDENDUM.
PROCESSING METHOD                                                                                                          CARD TYPE REMOVAL
CURRENT METHOD:              PAPER       EDC           ARU        CHANGE TO:         ARU         EDC                       REMOVE CARD TYPE:
POINT OF SALE (EQUIPMENT OR SOFTWARE)
NETWORK:            ELAVON           OTHER:                                           NETWORK CHANGE: CURRENT NETWORK:                                 CHANGE NETWORK TO:
VAR SERVICE PROVIDER (HOSTED):                        VAR VENDOR (DISTRIBUTED):                                                                                     GATEWAY (OPTIONAL):
                                                      VAR PRODUCT:                                                       VAR VERSION:                               AGGREGATOR:
      2ND DAY AIR             RUSH NDA –NEXT BUSINESS DAY: $                                 RUSH NDA -SATURDAY : $
                EQUIPMENT/PRODUCT                                                  SETUP          MONTHLY                                                                              PIN PAD             PRICE PER      TOTAL AMT DUE
 QTY                                           ITEM CODE       NEW/USED                                            PER AUTH         PURCHASE      EXCHANGE*           OWNS
                                                                                                                                                                                                                          (PURCHASE ONLY)
                   DESCRIPTION                                                      FEE             FEE                                                                               EXCHANGE*              UNIT
                                                                               $                 $                 $                                                                                   $                  $
                                                                               $                 $                 $                                                                                   $                  $
                                                                               $                 $                 $                                                                                   $                  $
ALL APPLICABLE STATE AND LOCAL TAXES WILL BE APPLIED.                 SALES TAX EXEMPT (ADDITIONAL DOCUMENTATION REQUIRED.)
EXCHANGE / PINPAD EXCHANGE
QTY        EQUIPMENT DESCRIPTION                                      ITEM CODE                                         PRICE PER UNIT                                               EQUIPMENT BACK FROM MERCHANT
                                                                                                                $                                   USED

                                                                                                                $                                   USED
ADDITIONAL SERVICES                      VISA/MC       DISCOVER ACQ         UNION PAY                                  AMERICAN EXPRESS                 AMEX RVRS. PIP/SPLIT DIAL
REQUIRED                              (ADD RATES FOR NEW CARD TYPE(S) IN PRICING SECTION)                              PIN BASED DEBIT                  EBT FCS#             EBT AUTH FEE $
IP COMMUNICATION METHOD: (IP DEFAULT)                                  IP            DIAL
   RETAIL (AUTO CLOSE DEFAULT)                                         QUICK CLOSE       INVOICE PROMPT                 B TO B (PROMPT ALL)  NO SIGNATURE                 CONTACTLESS (W/NO SIGNATURE)                 STORE & FWRD/BAM
   RESTAURANT (QUICK CLOSE DEFAULT)                                    TIP FUNCTION W AITER                             TIP FUNCTION CASHIER                              FINE DINING                                  TAB FUNCTION
   CARD NOT PRESENT (AUTO CLOSE DEFAULT)                               QUICK CLOSE                                      INVOICE PROMPT                                    B TO B (PROMPT ALL)
  LODGING (QUICK CLOSE DEFAULT)                                        QUICK STAY
MULTI MID REQUEST:                                                  NEW MERCHANT RELATIONSHIP                          DBA:                                                       MID RANK ORDER* (1,2,3…):
                                                                    EXISTING MERCHANT RELATIONSHIP:                    EXISTING MID:
*NOTE: IF THERE IS AN EXISTING MID, THAT MID ALWAYS DEFAULTS AS THE MASTER MID (OR MID #1)
PHONE INFORMATION:                                                  ACCESS #:
TRAINING REQUIREMENTS:                                                 NO TRAINING                TRAINING ONLY                                DOWNLOAD ONLY                       DOWNLOAD AND TRAINING
(NO TRAINING DEFAULT)                                               CONTACT NAME:                                                                      CONTACT PHONE #:
PRICING INFORMATION             (FOR PROCESSING METHOD / CARD TYPE CHANGE ONLY)

   TIERED                                     VISA                   MasterCard                         Discover                    Union Pay              DEBIT PRICING:         PASS THROUGH (INTERCHANGE + MARKUP - ICDIF)
Or    ENHANCED ICPLUS                 Rate% + Per Item              Rate% + Per Item               Rate% + Per Item             Rate% + Per Item                                  PASS THROUGH (INTERCHANGE + MARKUP - ICPLUS)
QUALIFIED                                      %+$                          %+$                            %+$                           %+$                                      SURCHARGE (FLAT RATE)
REWARDS QUAL
(T-opt / EIC-req)
                                               %+$                          %+$                            %+$                           %+$               DEBIT AUTH PRICING:          Fixed (FLAT RATE)
MID-QUAL                                       %+$                          %+$                            %+$                           %+$                                          PASS THROUGH (INTERCHANGE + MARKUP - ASSOC)
NON-QUAL                                       %+$                          %+$                            %+$                           %+$                   Apply to All (If Selected, Do Not fill out individual networks)
OTHER TIER                    CHECK CARD (T-OPT /EIC-REQ)            SUPERMARKET (T-OPT/EIC-NA)             QPS/SMALL TKT (T-OPT/EIC-NA)                                          %+$                      Auth $
                                               %+$                          %+$                            %+$                           %+$                   ACCL (ACCEL)                        %+$                   Auth $
COMM CRD (T-OPT /EIC-REQ)                      %+$                          %+$                            %+$                           %+$                   AFFN                                %+$                   Auth $
PASS THRU:                                    VISA                   MasterCard                         Discover                    Union Pay                  ALAS (ALASKA)                       %+$                   Auth $
   IC PLUS OR         IC DIFF         Rate% + Per Item              Rate% + Per Item               Rate% + Per Item             Rate% + Per Item               MSTO (MAESTRO)                      %+$                   Auth $
MARKUP                                         %+$                          %+$                            %+$                           %+$                   NETS                                %+$                   Auth $
   DIFFERENTIAL                               VISA                   MasterCard                         Discover                    Union Pay                  NYCE                                %+$                   Auth $
(Pricing Prg:         )               Rate% + Per Item              Rate% + Per Item               Rate% + Per Item             Rate% + Per Item               INKL (INTERLINK)                    %+$                   Auth $
QUALIFIED                                      %+$                          %+$                            %+$                           %+$                   ITS (SHAZAM)                        %+$                   Auth $
NON-QUAL                                       %+$------                    %+$------                      %+$------                     %+$------             CU24                                %+$                   Auth $
RATES ARE FOR ALL CARD ACCEPTANCE TYPES SELECTED. ALL CARD BRAND ASSESSMENTS WILL BE PASSED THROUGH AT COST.                                                   STAR (EXPLORE)                      %+$                   Auth $
CURRENCY EXCHANGE                                                                                                                                              PULSE                               %+$                   Auth $
   DYNAMIC CURRENCY CONVERSION (DCC) – REBATE:                        %     DCC ANNUAL REGISTRATION FEE: $
                                                                                                                                                               OTHER                               %+$                   Auth $
OR     MULTI-CURRENCY
CARD ACCEPTANCE (FOR PROCESSING METHOD / CARD TYPE CHANGE ONLY)                                                                                                               OTHER CARD TYPES EXISTING
   ALL VISA/MASTERCARD/UNIONPAY/DISCOVER (JCB, DI)                      VISA CREDIT        VISA DEBIT     MC CREDIT      MC DEBIT      UNIONPAY      DISCOVER (JCB, DI)                              SE #                         AUTH FEE
REPORT TOOLS                                                                                                                                                                  AMEX (10 DIGITS)                                    $
   MCP OR           MCP    W / OCM     MONTHLY FEE $                 SETUP FEE $                  # USERS              SET UP TYPE (ONE)       MID         CHN      ENT       OTHER                                               $

   ACS               MONTHLY FEE $                         SET UP FEE $                                                                                                       DISCOVER*                                           $
                                                                                                                                                                              *FOREIGN NETWORKS OR RETAINED LIST ONLY
SIGNATURE
BY SIGNING BELOW , MERCHANT WARRANTS THE TRUTHFULNESS AND ACCURACY OF THE INFORMATION PROVIDED, AGREES TO PAY THE FEES SET FORTH HEREIN.

_______________________________________                              ___________________________________________                                      __________________________
SIGNATURE                                                            NAME & TITLE                                                                     DATE
            VER: 042012

								
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