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HomeMy WebLinkAboutContract 2338 • bro'r•.� 42, 118 `: e °' - , fib MERCHANT APPLICATION AND AGREEMENT * FINANCIAL Agent Code / ' . J� „ [ pr^f Merchant # Sales Rep Signature; _ f , 5 E ?JCSS P rint Sales Re • Nam Sales Re. Phone #: `%5 2. -73b - t 7au^ BUSINESS INFORMATION Bus neat Open Date State In which papers Type of Business were filed ALA/ LV, ,� . 7aA- , egad env!! of Business: T of Goodsl5ervlcos said; City of Columbia Heights 1.�taJ z. 15 9A (doing business e$); Are you now processing or have you ever processed MasterCardNtsa/Discover@ Network? Top Valu Liquor I, Top Valu Liquor II, Heights Liquor El Yee Nan OfPra asor: P q P q 9 q CI No If ee, attach a . r+svlous P • • - .* a ,r - inert. Mailina/R.i11ng Address: Length of Current Ownership; # of Locations: 590 -40th Avenue NE City, Siete, Zip: Average Mon y ■o tine Average Ticket Amount or r eat - caked Amount for Columbia Heights, MN 55421 forMCN/DIacover MCN/DlscoverNetwork; MCN /DisooverNetwork: 9 Netw•de $ jr'}D, v6el t; c:). ,C $ W . da Contact Nellie: �) Sue Sartwell *' ,aped % Fare to Fare % Phone Number: Pax ffumber. 763 706 - 3632 763 - 706 - 3637 Keyed with imprint % Mari Order (MO/TO) % Merchant E-Mell Address: Merchant URI.; sue. sartwell @ci.columbia heighis.mn.us www.ci.columbia hei • hts.mn.us Keyed without Imprint K % internal ... 9'0 Location Address (if different from Mating); TOTAL 100% TOTAL 100 °1. See Attached for Location Addresses City, State, Zip: Products /Services art delivered In: D - days 1Or) % Columbia Heights, MN 55421 Country: Contact Name: 0 -14 days _ % 10 - 30 days % United States Larry Scott Over 30days % Total =100% Phone Humber. Fax Number: Have you ever had a benkcard relationship terminated? 763 - 706 -819 763 - 706 -3637 /14 No [1 Yes Do you use any third party to store, process or transmit cardholder date? ❑ Yes iiI1 No if Yes, Reason: Termination Date: 1 _, i Iva Name /Address: Please identify any so =re used for storing, trentmitting, or proceaeing Card • eaeonal Bales: Trenseotioneor +' masts: ■Yea : ■ No Heh Volume Months: _ OWNERSHIP INFORMATION , 61% ownership fora corporation, 100% ownership for a pdrblership or proprietorship, must be accounted for on Mc AOledtOOn. Federal Tax ID # (9 digits): I• El Sole Pro., ❑ Partnership ❑ Corpore$on El Other: 11 s ' ' e , • -.11 1.• Owner 1/Pe nor /Officer Name; ' Ills in = uainees: •wners Ip °. Cit of Columbia ■ -'. 1 5 160 Shia, Zl•: 11, 711 Social ineourity e: Phone Number: DOB: N/A • •.- ••• •wner 2/P= ner/Offlcer Name: Its in Business: Ownership % Home Address: City, State, Zip: Boatel Security #: phone Number. DOB: CEFERENC[as Trade Ra • rence 1 Name: Conterk Phone Number: EIIMMBI Trade Reference 2 Name: Contact: Phone Number: SETT I._F.,MF - N I /1!.: NT ( y0t.t MUST ded check) We will autarneUoally debit your Settlement Account for any amounts owed to ua under the Merchant Application and Agreement _. A voided check • Checking Only Contact Name: Bank ame: from this a ccount phone Number DDA Number. must be attached _._�. EQUI MFNT /DOWNL()AU :INFt7,RM4T; ION .. .................._...:__... _._ ._�.�____ room ships equipment YES ❑ NO ❑ Manufacturer: Model Printer PIN Pad ©htyperoom - ©VeriPone 0 Lipman/Nudt PC Software fin tC,o.fi 'r RitiS” _..... ❑ Gateway ❑ Other 02007.2008 Mandel Trenrscilon Bervlees. All rights reserve(. Fags 1 of 12 FTS0200$ Financial Transaction services Is a registered 060 /MSP for Wails Fm+go Bank, NA., Walnut Creek, CA. an FDIC insured bank. All lredemerks, service manta end trade names referenced in 04 Material are the property or their reipaaive owners. • ZOO 'd IOLI 9EL — Z56 ,oH )(lid sPliDulS .zazRtH Yid IZ:ZO 11E10I0Z /1Z /,L00 City of Columbia Heights Municipal Liquor Store Locations Top Valu Liquor I 4950 Central Avenue NE Columbia Heights, MN 55421 Top Valu Liquor II 2105 -37 Avenue NE Columbia Heights, MN 55421 Heights Liquor 5225 University Avenue NE Columbia Heights, MN 55421 Please send all correspondence to: Sue Sartwell Budget Coordinator City of Columbia Heights 590 -40 Avenue NE Columbia Heights, MN 55421 Phone (763) 706 -3632 Fax (763) 706 -3637 sue.sartwell @ci.columbia - heights.mn.us EQUIPIVIENT /DOWNLOAD INFORMATION Cont., n e More piney to be p fife• on Are we reprogramming eadstIng equipment? : YES 0 NO receipts: MANUAL IMPRiNTERS Terminal Appircation •type: 15 there on existing imprinter of this locatlen? NO REFUNDS ALLOWED Yes NO NO REFUNDS, EXCHANGE ONLY AV8 Prompts YES Tail NO ❑ ATM Dealt YES 0 NO A T e of Imprinter circle one) IN7DAYS (Type SALES FINAL Cell Waiting YES NO Auto Close YES ❑ NO Portable or regular manual Agents must do efl dorm/parrs alnd PBX Used YES 0 NO D Time; (may) tnstels. Shared Line YES ❑ NO ❑ CREDIT CARD ACCEPTANCE ENTITLEMENTS Check those cards you choose to accept (acceptance of all MasterCard (MC). We New Amertcen Express Agreement Attached: Yea • No • and Discover Network transecfons Is presumed unless any selections below are checked (see section 2): Please provide the following MID #'s when available: ❑ Aeeept MC Cledit TransacUons ❑ Accept MC Non - PIN Debit Transaction • Only Only Amex: JCS: ❑ Accept Visa Credit Transactions ❑ Only Accept Visa Non -PIN pablI Transactions Ortly Check guar: Q Accept Discover Network credit Transactions Only Cheek guar CO.: ❑Accept Discover Network Non PIN Debit Treneao0ans Only Check guar method: Drivers License ❑ MICR ID •••Note: If no box to checked It wiu autometioatly deleuit to Driven License. PETROLEU INFORMATION Pay at the Pump: YES ❑ NO ❑ ❑ Wright Express: 3.50% Transaction tea: 190 ❑ voyager Rate; 3.40% transaction fee; 8� Charged by Processor Integrated Equipment ❑ VeriFone Ruby ❑ Auto Sas ❑ Oaa Boy 0 Gilberto ❑ Other: EBT INFORMATION The EST Services Riders to Buypaaa Corporation and Schedule 1 must accompany the application FN8 #: Trans Fee: Benefit Issuance Avelability: Days Hours _. Electronic Voucher Support Yes ❑ No ❑ Oiled( all eST services provided at this location: ❑ Feed stamps ❑Cash Benefits f,7Purobase with Cash Back ❑Purchase ❑Cash withdrawal If cat issuance, the limit amount: S SCHEDULE OF FEES (CI rdr yd by Processor) All : = =s gin= ,sub ;•:c to chin • a:- provic•adbalo x. For;uriher d =toilo, rood thin entire Merchant Application an Agreernunt. Three -Tier Pricing T Two -Tier Pricing DISCOUNT DISCOUNT Rate Tier Description fps Discount Rate (° /,) and Rate Tier Description for Discount Rate ( %) and Maetet'CardNisa/Disoover Network Dpw "grade F MeeterCnrd /WereDiscover Network Downgrade Fee Wei _ % "781761r144)..16"& { f • Co g• . D7' Rate 1 Rate 2 Rate 1 plus % + $_ Rate 3 Rate 1 plus _ryo + Ratea Rate 1 plus % +$_ AUTHORIZATION AND TRANSACTION FEES ACM Fee $ = /batoh Masts • =rd/VIea /DlacoverNetwork $ /each _ Authorization Fee American Express Authorization/EDC Fee $ _ /each Pm - Ruth Fee $ _ieach DetutrATM Transaction Fee (Plus Debit Network Processing Fees) $ • /each El Vital Fee $ leach Decline Fee $ /each Voice Authorization Fee $ #75 /each JCB Authorization /EDC Fee $ . feach Voice Response Untt (Vett) Fee S _ /each jl j;. 7•I''"r :r;*r;•!' �ij • li:� I 'a . O .. .... .. .. .. fFirR FEES ry. r � , n !l; jl`II ' l } I i I j'i1J j •�: •Ij;': a {' +y�', `) {;1•' Minimum M onthl y 9 t nimum on Discount Fee $ ail 1Ha.l�; �i� ;lit' .'.y�n.�ii��a7Y{� �, • • •" r, ', i9Y ly month Chargebeck Fee $ 30,00 /each Monthly Fee $ _ /month v Early Cancellation Fee • $ :'' . - Statement Fee $ j ,.rnonth ❑ Men:here Club Fee _(Initials) - MerShere wrp be Charger/ appf /cable &alas tax when 9Ivbre to $ _ health Retrieval Fee $ 7.60 /each rpaeive certain selected supplies et no additonal charge. • 02007.0005 Financial Transaction services, All rights reserved. Page R of 12 PTSO20&9 Financial Transaction Services is a registered ISD /M5P For Wets Fargo Bank, NA, Wetnul Crank CA. en FOXC insured bank, At trademarks, service marks and Made names fd!Weneed in the material are the property of the respective owners. • 900 ' d IOLI- 9EL -Z96 'AN Xbd sP.ziePuP1S ,zatI 1H Wd IZ :ZO IIH1, /OI0Z /IZ/100 SITE INSPECTION INFORMATION What % of total sales represent business tb business Business to Business % Business to Consumer % =100 % (total sales) va, business to consumer What % or banaerd safes represent buafneae to business Business to Buainees 5 fit + Business to Consumer 14 % = 100 % (bencard sales) (vs. business to consumer)? Tlmetrame from transaction to delivery of produotreervioe; Percentage of orders delivered In: 0 -7 days ilc7Cy % + 8 -14 days . 3'a + lb - 30 dny6 % + Over 30 days % = 100 % Viaa/MeaterCardfDlecover sales era depoelted (chock one): ,E3 Date of order q pale of Delivery ❑ Other ( specify): Method of Advertising: ❑ Catalog ❑ Brochure/Direct Mail i:j TV /Radio ❑ Internet i Phone (attach a copy of at least one) JI L Newspaper /Journal ❑ Other (specify): Who performs product/service fulfillment? xi Direct ❑ Vendor If Vendor, please provide name, address end phone number Describe how the transaction works from order taking to merchant fulftiiment: L412LASIVIZ What card transaction verification steps do you take to protect against cardholder misuse? (i.e., address verification, CAU backs, etc.) ta, .••, 4- %0C ++• - -L' i..J.Gt'rw.SE vue. CF�CoLr Dose any of your cardholder billing Involve automatic renewals Or retuning t/arlsattians? (i,e„ cardholder authorises initial sale Only) Yes ❑ No If Yee, comments: Do you have a website? Yes ❑ No If Yes, please provide website li RL: wurw. What type of data enm do you employ to protect cardholder Account numbers when they am transmitted over a public data network, from the cardholder to your merchant websita? 0 SET ❑ $$L (channel encryption) ❑ No encryption used • 020072008 Financial Traneaotlm SWAM. All rights reserved. Page 3 of 12 FTS0208s Mendel Transaction Services is e registered ISO /InSv for Wells Fergo Berk, NA, wernut Creek. CA. en FDIC Insured bank, All trademarks, service marks end trade names referenced In ale material are the properly of their respeotive owners. 1700'd IOLI- 9£L- Z96'oN Xbd sp.zleP- S ae4 1H Yid IZ :ZO IlH1/0I0Z /IZ /J O AUTHORIZATIONS AND REPRESENTATIONS Each of the undersigned authorize Bank/Processor to use credit bureau /reporting agencies and/or their own agents to verify the aooureoy of all information provided herein and to assess and monitor each of me undersigned's credit status, glitch of the undersigned authorizes all such credit bureau /reporting agencies to release any Information they may have pertarning to him /tier to Bank/Processor. No aglow agent of Bank/Processor Is authorized to make any verbal or written modtflostion to this Merchant Application and Agreement and Operating Procedures. Do not sign below unless and until you have received and reviewed all pages of this Merchant Application and Agreement. I understand that the Initial term of this Merchant Agreement is thirty-six (SS) months, continuing month to month thereafter, and that account termination prior to the expiration of the Initial thIrty -sb( (V3) month term shall require Merchant to pay an Early Cancellation Fee to the amount of seven hundred and fifty dollars ($760.00). I aoknowiadge that this complete and legible Merchant Application and Agreement has been provided to me, and I agree to be bound by its provisions. I understand that I have been provided Operating Procedures, which contain the operating procedures, instructions and other directives relating to Card transactions wig be provided separately, I agree that if I process Card transactions, i will comply with the Operating Procedures for all transactions I process. I understand that I also may request a copy of the Operating Procedures from my sales representative at any time. I further understand that no strikeouts, Interlineatlons, additions or modifications to this preprinted Merchant Applioatlgn and Agreement may be made and that this Merchant Application and Agreement may be transmitted to or from Processor and/or retained electronically by Processor, which will constitute an original, I understand that this Merchant Application and Agreement is subject to approval by Processor end Banat. I declare under penalty of perjury under the laws of the state of California and under the laws of the state in which my business is located that all of the o d in this Apptoatlon is true and complete, / Walter r R. R. F ehst, City Manager ✓��rld Print Name of Principal or Corporate Officer Signature (Title) a te / l0 cR � O Print Name of Principal or Corporate Officer Signature (Title) Date PERSONAL GUARANTOR All corporations and limited !lability companies must have their obligations guaranteed. As a primary Inducement to Bank/Processor to enter Into this Merchant Agreement and/or Third Party Agreement(s) and any addendum, or attachment thereto, with Merchant, the undersigned Guarantor(s), by signing this Merchant Application and Agreement and any addendum or attachment thereto, Jointly and severally, unconditionally and Irrevocably, guarantee the continuing full and faithful performance and payment by Merchant of each of its duties and obligations to Bank/Processor pursuant to Ibis Merchant Agreement and /or Third Party Agreement(s), as It now exists or as It may be amended from time to time, whether hefore or after termination or expifation and whether or not Guarantor has received notice of any amendment. if Merchant breaches its Merchant Agreement and/or Third Party Agreement(s), Bank/Financial Processor may proceed directly against Guarantor or any other person or entity responsible for the performance of the Merchant Agreement and /or Third Party Agreement(s), without first exhausting their remedies agai any of -r n or entity respon ibis therefore to them, or any security held by Bank. 1 City of Columbia Heights R /� rn' Name of Personal Guarantor Signature, • an to (victual (No title) Date Print Name of Personal Guarantor Signature, as an individual (No title) Date Wells Fargo Bank, N.A. (for Visa and MasterCard transactions) Accepted by Financial Transaction Services, L,LC Signature Signature For internal uee only: SIC/MCC Code t a 2007 -7505 Financial Trenaadlcn Services, All dehis taesr;ed. Page 11 0112 FT602088 Financial Transaction Services is a registered ISO /MZP for Wets Forgo Pew N,A., WelnutGreek, CA. an FDIC Insured bank. All trademarks, service media and trade names referenced In rhle material are the property or their respedIve owners. SOO 'd IOLI- 9£L -Z96 'ON X'J, spaiepulelS . Rd IZ:ZO IlH1/0I0Z /IZ /,100 MIME Bank Information and Merchant Responsibilities Disclosure Page Member Bank (Acquirer) Information Acquirer Name: Wells Feriae Dank, N.A. Acquirer Address; MAP A0347 -023 1200 Montego ay Walnut Creek. CA 94598 Acquirer Phone: 925- 746 -4167 Important Member Bank (Acquirer) Responsibilities 1. A Visa Member is the only entity approved to extend acceptance of Visa products directly to a Merchant. 2. A Visa Member must be a principal (signer) to the Merchant Agreement. 3. The Visa Member Is responsible for educating Merchants on pertinent Visa Operating Regulations with which Merchants must comply. 4. The Visa Member is responsible for and must provide settlement funds to the Merchant. 5. The Visa Member is responsible for all funds held In reserve that are derived from settlement. Merchant Information Merchant Name: Top Valu Liquor I Top Valu Liquor II Heights Liquor Merchant Address: 4950 Central Ave NE Columbia Heights, MN 55421 2105 -37th Ave NE Columbia Heights, MN 55421 5225 University Ave NE, Columbia Heights, MN 55421 Merchant Phone: 763- 706 -3819 763- 706 -3813 763- 572 -9730 Impotent Merchant Responsibilities 1. Ensure compliance with cardholder data security and storage requirements. 2. Maintain fraud and chargebacks below thftsshold5. 3. Review end understand the terms of the Merchant Agreement. 4. Comply with Visa Operating Regulations. The responsibilities listed above do not supercede terms of the Merchant Agreement and are provided to ensure the Merchant understands some important obligations of each party and that the V sa Member (Acquirer) Is the ultimate authority should the ercha t ha" y p :le s. • Merchant 8igneture Date Walter R. Fehst, City Manager Merchant's Printed Name & Title • • v2007 -2008 Finanolal Traneeotlon Services. All ?Igme reserved. Page 12 of 12 FT80200S flnanOal Transaction Services Is a registered ISO /M5P for Wtlls Fargo Bank, NA., Walnut Creak CA. en FOIL Insured bank. All trademarks, service marks and trade names rcfarvrraed In this materiel are the property of their respective owners. 900'd I0L1- 9£L -Z96 ON XVd sP.zePuelS Jett ?H Y(d IZ :Z0 .011 /0I0Z /IZ /1,00