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Home My WebLink AboutContract 2342 ri i;2342� , ; a � ,fix ; ,.p 403191 C (9/091 This box will be completed by an American Express representative. ❑ New Signing ❑ Update ❑ S/E ❑ CAP ❑ MAP Industry Code Origin Code C5 Sales # I SE# ( 1 I I I I I I I I I X -Ref 1 1 1 1 1 1 1 1 1 1 1 Affiliation Code I I I Affiliation Pay Frequency (3/15/30 days) 1 I I ❑ Recurring/Automatic Bill Pay High -ROC Rate L - 1 I 1% High -ROC Threshold $ I-I__ Discount Rates: EDC i_I I__J% Paper L1 1 phi Prepaid L_1 1 1% or $0. I I Non - swiped Transaction Fee �V,i ' l ' ❑ Retail + 100 transaction fee ( +.30% Card Not Present Fee) ❑ Services, Wholesale, All Other + 150 transaction fee Estimated Volume $ (American Express Annual) 1 I 1 1 I 1 1 J I Estimated Average Ticket $ 1 I I I I 1 1 CPC Ll - I I 1% Pay Option 1 I I ❑ Daily Gross Pay Monthly Gross Pay ❑ Flat Fee ❑ Card/TO decal ❑ Accepts TCs Special Program(s), e.g., No Signature, Assured Reservation, Fraud Full Recourse: Please complete the following. If you have any questions call your American Express representative. 6 " of tian, r or Sole P �o i as regi r RS L - 1 I �� I I f rt er �j o l A pi t j K�.I- i I It 1 I I 1 I I I I 1 1 I I 1 1 1 D i 1 8usi (D�, T e Na T( r I (Y l 1 IL ll�u�.1� I I I ii-r: 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Ad dresss 1 ig Box numbers are not acceptable) 1 1 1 1 1 1 1 1 1 1 1 l 1 I I I 1 1 1 1 1 1 1 1re� +` ma ..�4 AI! MLA.. • .• ii1 l�i�I - h_ _.∎ II , ► - I I I I Business Phone Number* I all IOW: - _ .. Customer Service Phone Number 1 1 1 1 - 1 I I 1 - 1 11 1 I Fax Number' I I I I-I I I 1 II q Business E-mail Address` SL A , ' (� if 't k,` ' % I ''� ('t .0 x , K) 6 1 - J 'h , m r . IA Customer Service E-mail Address URL (Website)/Recurring (ABP) Enrollment Page Address Ownership Type: ❑ Corporation — Private ❑ Corporation — Publicly Traded ❑ LLC - Private ❑ LLC— Publicly Traded ❑ Partnership — Private ❑ Partnership — Publicly Traded ❑ Sole Proprietorship ovemntent ❑ Non -Profit Time Under Current Owner (yymm) I I I I I Stock Symbol I I I I I I I I DUNS Number (if applicable) I I I I I 1 1 1 1 SIC Code I I I I I D this business have employees or a Federal 1 Tax ID nu er /, Yes — please provide your Federal Tax ID number 11 11 �l � l's � � ,{I 1 iNo. you have no employees — please provide your Social Security Number I 1 I 1 - I 1 1 - 1 I I I I Processor Information: Name Toll -Free Number Merchant I.D. . " By signing this form, you authorize American Express Company to send you account information & exclusive offers and savings for your business via the information : that you have provided. For information on how we use your information and protect your privacy, please visit us at www.americanexpress.com /privacy. Electronic Payment Information / "t ABA ank Routing) lu xi I 9, I . ' � I I � i ,�/ D DA (Bank Account) Number r' � Bank Name j ^ � Which reporting method do you prefer? line Merchant Services ❑ Calendar/Month (paper— additional fee applies) (Monthly End Date ) • ATTACH VOIDED BUSINESS CHECK ided Check Collected & Verified? ❑ Yes 403191 C(9/091 US .-,,.._.- _ 403191 C(9/091 Other Information Please provide any additional addrs{esjWlow. If additional information must be sent to the address, please check the appropriate box(es). 0 Check 0 Correspondence elcome ICt 0 Supplies N ATTN: Addressil HIM Ill I I I I 1 1 1 111 Addrass211111111111111111111111111 cit statelll DP111111-11111 Significant Owner Please provide the following information for any significant owners Ithose who control 25% or more) of your business. If there is no single owner controlling 25% or more of your business, at least one owner's information must be specified. First ''1111111111IIIIIIIIIIIr 11111 Address (PO Box numbers are not acceptable) 111111111 IIII 111111111 IIIII 1111111 Cit •IIII1IIIIIIIIIIIIIIIIIIIII11IIIII State ZIP Country Owner % Social Security Number or Date of Birth (mmddccyy) 1111111 Id 111111 III! 11111 I I I I I I I I I First Last 1111111111111111111111111111111111111 1111111 1111111 Address WO Box numbers are not acceptable) II I I I I I I I I I I I I I I III II 1111111111 City 111111111111111111111 State ZIP Country Owner % Social Security Number or Date of Birth (mmddccyy) 1, 1 I I I I I I Id 111111 111111111 i-Ill-ill 1 1 1 1 1 1 1 1 1 I First Lest :1111111111111111111111111111111111111 1111111111111 Address (PO Box numbers are not acceptable) IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII City HI111111111111111111111111111 I 111 State ZIP Country Owner % Social Security Number or Date of Birth (mmddc l I I 1 1111111111111.111-111 11111 Fast Last 1111111111111111111111111111111111111 1111111111111 Address (PO Box numbers are not acceptable) il I III 111111111 II III City State ZIP Country Owner % Social Security Number or Date of Birth (mmddccyy) I I I I I I I I I I 1 I I I - 1 I 1 I I I I I I I I I I I I I Authorized Signer Information (You must provide first and last name.) '• Name: Walter R. Fehst Title: City manager • Status: 0 Sole Proprietor 0 Partner 0 Corporate Officer X Municipality Have you previously had an American Express Merchant Account Number? 0 Yes 0 No If Yes, Merchant Number By signing below. I represent that I have read this Agreement (including this Application/Set Up page and the Terms and Conditions) and can sign for the entity above, which agrees to be ( bound by this Agreement. I authorize American Express to verify the information above and receive and exchange information about me personally, including by requesting reports from consumer reporting agencies. I authorize and direct American Express to inform me directly, or through the entity above, of reports about me that American Express has requested from consumer reporting agencies. Such information • • 'nclude the name and of the agency furnishing the report. I also authorize American Express to use the reports from consumer reporting agencies for marketing and adm rposes. D 12/02/2010 403191 C (9/091 S _ US - GOVERNMENT & PUBLIC UNIVERSITY MERCHANT SETUP FORM NOTE: SET UP SHEETS WITHOUT CONTRACTS WILL BE REJECTED Amex MBD #/Name:06DD Teresa Chaffee Phone #: 612.839.9892 teresa.m.chaffee@aexp.com Signing Date (month/day/year): 12/02/10 If This Signing Is A Dependent Under A Master Agreement, which Master: NO Affiliation Information: CAP #: 3220450217 MAP #: Type of Government Account (SIPGM Code): 022 City Gov't Federal Tax ID# 41- 6005069 Origin Code: City 19 Account Name: City of Columbia Heights DBA Name: Top Valu Liquor, Top Valu Liquor II, Heights Liquor 4950 Central Avenue NE 2105 37th Avenue NE 5225 University Avenue NE Address 1: 590 40 Avenue NE Address 2: City: Columbia Heights State: MN Zip: 55421 Telephone #: 763 - 706 -3600 Fax #: 763- 706 -3637 Web Site of Business (if applicable) www.topvaluliquor.com Authorized Signer:Walt Fehst Authorized Signer Title: City Manager Contact Name: Sue Sartwell Contact E -Mail: Sue. Sartwel l @ci.columbia - heights.mn.us Additional Address: Attention: Sue Sartwell Reports ® Correspondence ® Supplies ❑ Other ❑ Discount Rate: 2.20 Est. CV$ 25,000 Avg. Charge 50.00 Category: Industry: 542 Education Industry Code: Government Industry Code: 542 City -Other CONTRACT: APA ❑ Custom ❑ Pre - Printed❑ GOVERNMENT & PUBLIC UNIVERSITY MERCHANT SETUP FORM SPECIAL HANDLING NEEDS: Will convenience fees be charged? Yes ❑ No Eg If Yes, who is charging the Convenience Fees? If No, the amount of the charge and the amount of the convenience fee must appear as separate charges, and the following information for payment of the convenience fee must be provided: Name of Bank ABA # DDA # Supply Information: Send Start -Up Kits: ❑ No ® Yes Send Supplies: ❑ No ❑ Yes To: Each Location? El HQ Address? ❑ Supplies Requested: # of Multi -Card Decals # of Multi -Card Plaques # of Amex Only Decals # of Amex Only Plaques Additional Supply Requests: Contract Completed By: Date Completed: Salesperson Name: Teresa Chaffee Telephone #: 612.839.9892 Merchant Number: CAP #: MAP #: Dependent #: 3