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MERCHANT PROCESSING APPLICATION AND AGREEMENT

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MERCHANT PROCESSING APPLICATION AND AGREEMENT Powered By Docstoc
					USAll1105         M E R C H A N T P RO C E S S I N G A P P L I CAT I O N A N D AG R E E M E N T                                                         USAll1105

Print Sales Rep Name ____________________________________________________________

Merchant Number ___________________________________________                   Sales Rep. Signature ________________________________________________________

                                                                            1 B U S I N E S S I N F O R M AT I O N
                                                                             .                                                                                                   Page 1 of 3
 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:            Zip:                  City:                                                 State:        Zip:


 Location Phone #:                                Location Fax #:                                    Contact Name:
 (            )             –                     (                )              –
 Business E-mail or Website Address:              Customer Service Phone #:                          Contact Phone #:                              Contact Fax # / E-mail Address:
                                                  (            )              –                      (           )            –
 Send Retrieval Requests to: ■ Business Location             ■ Corp/Legal Location                  Send Merchant Monthly Statement to: ■ Business Location          ■ Corp/Legal Location
 ■ INDIVIDUAL / SOLE PROPRIETORSHIP: State in which Certificate of
                                                                                      ■ TAX EXEMPT ORGANIZATION (501C) State: ________              ■ GOVERNMENT (Federal, State, Local)
     Assumed Name Filed: _____________________________ State: _______
                                                                                      ■ INTERNATIONAL ORGANIZATION                                  ■ LIMITED LIABILITY
 ■ CORPORATION – CHAPTER S, C               State: _______                                 Location Filed: ________________                             COMPANY       State Filed: ________

 ■ MEDICAL OR LEGAL CORPORATION State: _______                                        ■ ASSOCIATION / ESTATE / TRUST State Filed: ________          ■ PARTNERSHIP State Filed: ________
 FEDERAL TAX ID # :                                                     Detailed Explanation of Type of Merchandise, Products or Services Sold:

 SIC / MCC:


                            2 . A D D I T I O N A L C R E D I T / S I T E S U RV E Y I N F O R M AT I O N – A L L M E R C H A N T S
1.    Zone:       ■ Business District       ■ Industrial       ■ Residential          15. Your Previous Processor: _________________________________________________________
2.    Location: ■ Mall          ■ Office        ■ Home     ■ Shopping Area            16. Check Reason For Leaving:
                ■ Mixed         ■ Apartment     ■ Isolated
                                                                                          ■ Rate ■ Service ■ Terminated ■ Other: ___________________________________________
3.    How many employees: ____________
4.    How many registers / Terminals: ____________                                          Mail / Telephone Order / Business to Business / Internet Information
                                                                                                                           (All Questions must be Answered)
5.    Is proper license visible? ■ Yes
                                                                                      1.    What % of total sales represent business to business (vs business to consumer):
      ■ No, explain: _____________________________________________
                                                                                            Business to Business ______%          +   Business to Consumer ______%    = 100% (total sales)
6.    Where is the merchant name displayed at the site?
      ■ Window       ■ Door     ■ Store Front                                         2.    What % of bancard sales represent business to business (vs business to consumer):

7.    Merchant Occupies: ■ Ground Floor           ■ Other: __________________               Business to Business ______%          +   Business to Consumer ______%    = 100% (total sales)

8.    # of Floors/Levels:   ■1      ■ 2-4   ■ 5-10    ■ 11+                           3.    What is the time frame from transaction to delivery? (% of orders delivered in):

9.    Remaining Floor(s) Occupied by:                                                       0-7 days______% + 8-14 days______% + 15-30 days______% + over 30 days______% = 100%
      ■ Residential ■ Commercial ■ Combination                                        4.    MC / VisaDiscover Network sales are deposited (check one):      ■ Date of order
10. Approximate Square Footage:                                                             ■ Date of delivery       ■ Other (specify) : ______________________________________________
    ■ 0-250 ■ 251-500 ■ 501-2,000               ■ 2,001 plus                          5.    Who performs product / service fulfillment?      ■ Direct   ■ Vendor    ■ Other If vendor, add
11. Are customers required to leave a deposit?
                                                                                            Name: __________________________________________________________________________
    ■ No ■ Yes If Yes, % of deposit required: _______%
12. Return Policy: ■ Full Refund        ■ Exchange Only            ■ None                   Address: ________________________________________________________________________
13. Do you have a refund policy for MC / Visa / Discover® Network                           City / State / Zip: __________________________________ Phone: __________________________
    Sales? ■ Yes ■ No If yes, check one:
                                                                                            Please describe how the transaction works, from order taking to merchant fulfillment
    ■ Exchange ■ Store Credit ■ MC / Visa / Discover Network Credit
                                                                                            (attach additional sheet if necessary) :
      If MC / Visa / 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                     ■ TV/Radio
                                                                                             _______________________________________________________________________________
    ■ Internet ■ Phone          ■ Newspaper /Journals ■ Other
    Marketing Materials required for Mail Order, B to B, Internet over                6.    Does any of your cardholder billing involve automatic renewals or recurring transactions
    $1 Million in annual volume. Attach Web Page for Internet Merchant.                     (i.e. cardholder authorizes initial sale only) ? ■ Yes ■ No
                                                                                  3 . C O M PA N Y H I S TO RY

Date Business Started:                                         Prior Bankruptcies?         ■ No      ■ Yes             ■ Business and / or    ■ Personal
                                  TRADE REFERENCE 1                                                                                    TRADE REFERENCE 2

Vendor Name:                                                                                         Vendor Name:

Address:                                                                                             Address:

City:                                                 State:                 Zip:                    City:                                              State:            Zip:

Contact Name:                                                                                        Contact Name:

Contact Telephone:      (                   )                                                        Contact Telephone:       (                )

Vendor Acct. #:                                                                                      Vendor Acct. #:
                                                           US Alliance Group is a registered ISO/MSP of Wells Fargo Bank, N.A.
                                                       Bank Copy - White • Sales Representative Copy - Yellow • Merchant Copy - Pink
DBA Name: _________________________________________________________________________                            Merchant #: ___________________________________________________

                                                             4 . OW N E R S / PA RT N E R S / O F F I C E R S                                                                 Page 2 of 3
                             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:                    City:                                                   State:           Zip:



 Telephone #:                                                                                 Telephone #:

 (                      )                      –                                              (                        )                          –
 Social Security #                                                                            Social Security #



 D.O.B.:                DI #:                                        State:                   D.O.B.:                      DI #:                                    State:



                                                                  5 . S E T T L E M E N T I N F O R M AT I O N

 Deposit Bank:                                                                                Bank Contact:

 Transit / ABA #:                                                                             Deposit Account #:
                                                       6. T H I R D PA R T Y / G R I D I N F O R M AT I O N

 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:___________________________________________

 Authorization Grid ID#: ___________________________________________________                  User Defined Grid ID#: ____________________________________________________
USAll1105                                                     7 . T R A N S AC T I O N I N F O R M AT I O N                                                                   USAll1105
                                                        FINANCIAL DATA                                                             WHERE IS SALE TRANSACTED? (Must = 100%)

 Gross YEARLY Sales Volume (Cash + Credit + Debit + Check)                                            $_____________                 Store Front / Swiped              __________%

 Average YEARLY MC / Visa/ Discover Network Volume                                                    $_____________                 Internet                          __________%

 Average MC / Visa/ Discover Network Ticket (Estimate If Never Processed in Past)                     $_____________                 Mail Order                        __________%

 Highest Ticket Amount                                                                                $_____________                 Telephone Order                   __________%

 Seasonal?       ■ No       ■ Yes                                                                                                    Total                                  100
                                                                                                                                                                       __________%

 High Volume Months Open: ___________________________________________________________________

                                                                     8 . S E RV I C E F E E S C H E D U L E
                                                         Authorization & Capture Transaction Fees


 MasterCard, Visa and Discover Network Authorization & Capture Fee: $___________ (Per Item)                                            Voice Authorization             1.00
                                                                                                                                                               $_____________ (Per Item)

 American Express Authorization: $_____________ (Per Item)                    JCB Authorization: $_____________ (Per Item)             Electronic AVS Fee              0.00
                                                                                                                                                               $_____________ (Per Item)

 Other Item:                          $_____________ (Per Item)               Other Item:              $_____________ (Per Item)       Voice AVS Fee                   2.50
                                                                                                                                                               $_____________ (Per Item)

 SE #: ________________________________________________                       SE #:____________________________________                ARU Fee                         1.00
                                                                                                                                                               $_____________ (Per Item)
                                                    Miscellaneous Fees                                                                                      Monthly Fees

■ Dues and                                                    Retrieval Fee                               Return
  Assessments        Chargeback Fee $_________ (Per Item)     (12B Letter) $_________ (Per Item)          Trans. Fee $_________ (Per Item)      Wireless Fee                  $_________

                                                                                                                                                Online Access Fee             $_________
Sales Trans. Fee $_________ (Per Item)       Batch Fee $_________ (Per Item)                                   395.00
                                                                                            Cancellation Fee $_________ (One Time Fee)

EBT –                                                               EBT –                                                                       Customer Service Fee          $_________
Food Stamps $_________ (Per Item) #:_____________________           Cash Benefits $_________ (Per Item) #:_____________________
                                                                                                                                                Debit Access Fee              $_________

Other: ___________________________________ $_________               Annual Fee: $_________              Pass ACQ ISA Fee? ■ Yes ■ No
                                                                                                                                                Gold Package                  $_________

Minimum Monthly Fee $_________                                      Monthly Statement Fee $_________ (Account on File)                          Other:__________________      $_________

                                                       US Alliance Group is a registered ISO/MSP of Wells Fargo Bank, N.A.
                                                   Bank Copy - White • Sales Representative Copy - Yellow • Merchant Copy - Pink
DBA Name: _________________________________________________________________________                        Merchant #: ___________________________________________________

                                                                8 . S E RV I C E F E E S C H E D U L E (cont’d)                                                       Page 3 of 3
Tiered
                        Accept all MasterCard, Visa and Discover Network Transactions                                                                Fleet
                                (presumed, unless any selections below are checked)
                                                                                                                               Wright Express:      Other Item Rate $__________
      MasterCard Acceptance                                            Visa Acceptance                                                                                (per item)
    ■ Accept MC Credit transactions only                             ■ Accept Visa Credit transactions only                    Voyager:
    ■ Accept MC Non-PIN Debit transactions only                      ■ Accept Visa Non-PIN Debit transactions only               Qual ______%       Other Item Rate $__________
                                         Discover Network Acceptance                                                                                                  (per item)

                                       ■ Accept Discover Network Credit transactions only
                                                                                                                                                 TeleCheck
                                       ■ Accept Discover Network Non-PIN Debit transactions only
                                                                                                                               ■ Split Dial ■ License # ■ MICR ■ Warranty ■ ECA
                    See Section 1.9 of the Program Guide for details regarding limited acceptance.
 ■ Discount Collected          ■ Daily     ■ Monthly                                                                           SE Number ___ ___ ___ ___ ___ ___ ___ ___

■ Pass Through Interchange – Includes Dues and Assessments                                                                     TeleCheck Rates & Fees ■ Yes ■ No
                                                Discount                                                     Discount          Inquiry Rate                           ___.__ __%
                                                                    (Based on                                (Based on
                                                               Gross Sales Volume)                       Gross Sales Volume)                                               .10
Other Item Rate         $____________                                                                                          December Risk Surcharge                ________%
                          (per item)
                                            MC Qual Credit                      % Visa Qual Credit                        % Per TXN Fee                               $_________
Other Volume Percent _________%                                                                                                                                          25.00
(Based on Net Volume)                       MC Qual Debit                       % Visa Qual Debit                         % Monthly Minimum Fee (Per Location)        $_________
                                            Discover Network                      Discover Network                                                                        5.00
                                                                                                                               ACH Processing Fee                     $_________
                                            Qual Credit                         % Qual Debit                              %
                                                         PIN Debit                                                                                                       2.50
                                                                                                                               Client Requested Operator Call (CROC) $_________

                                                                                                                        ECA Chargeback Fee                                5.00
                                                                                                                                                                      $_________
 ■ Pass Through Debit Network Fees            Other Item Rate $_________ (per item)      Other Volume Percent ________% (Only charged when entitled with TeleCheck)
USAll1105                                                                         9. SIGNATURE(S)                                                                     USAll1105
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 USAll1105) and Confirmation Page, which is part of this Merchant Processing Application (consisting of Sections 1-9), 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 7, Transaction Information section above, you are authorized to accept transactions in accordance with the percentages indicated
in that section. Client authorizes US Alliance Group 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 US Alliance Group 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.
The individual who signs this Agreement has authority to do so and to bind its Establishment to the terms and conditions of this Agreement. You further represent that you
are authorized to sign and enter into this Agreement on behalf of your establishment, subsidiaries and affiliates, and that you authorize American Express Travel Related
Services Company, Inc. to verify the information on this Application.
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 US Alliance Group and Bank.

Client’s Business Principal / Officer:


Signature   X_______________________________________________             Title________________________        Signature   X __________________________________________________

Print Name of Signer _______________________________________ Date _______________________                     Print Name of Signer ______________________________________


Signature   X_______________________________________________             Title________________________        Title________________________________ Date _______________


Print Name of Signer _______________________________________ Date _______________________

Personal Guarantee: The undersigned guarantees to US Alliance Group and Bank the performance of this Agreement 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. US Alliance Group 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 US Alliance Group and Bank. The term of this guarantee shall be for the duration of the Merchant
Processing Application and Agreement 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   ____________________________________________________                  Print Name: _____________________________________________          Date ______________


Accepted By US Alliance Group                                                         Wells Fargo Bank, N.A., 1200 Montego Way, Walnut Creek, CA 94598


Signature   X   ____________________________________________________                  Signature   X __________________________________________________________________

Title __________________________________________ Date ____________                    Title ___________________________________________________          Date _______________



                                                         US Alliance Group is a registered ISO/MSP of Wells Fargo Bank, N.A.
                                                     Bank Copy - White • Sales Representative Copy - Yellow • Merchant Copy - Pink

				
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