HomeMy WebLinkAboutContract 2012 2442 V7,iin(CB&T) •',
APPLICATION FOR MERCHANT CARD PROCESSING
STW Short Name: APT Assoc#: 918011
Sales Rep Name: Brent Kauth Sales Rep Code: Branch#:(if applicable)
For purposes of this application,Processor"or`TransFirst"is TransFirst Third Party Sales,LLC,or one of its TransFirst affiliates,located at 12202
Airport Way,Suite 100 Broomfield,CO 80021 and can be contacted at(800)654-9256. Additional information can be found on the TransFirst website,
www.TransFirst.com."Merchant Bank"or"Member Bank"is Columbus Bank and Trust Company, a division of Synovus Bank, located at 1125 First
Avenue,Columbus GA 31901 706 649-4900. Processor is a r-•istered ISO/MSP of Columbus Bank and Trust Corn•an .
1.BUSINESS INFORMATION
Legal N`aatme of Business (25 characters max) DBA Name (25 characters m�axx))
Le
Legal lid o u r ` t ��5 DBA Address(Physi�lcation,no Boxes)
Sao 46114 Ave. NE
City State ZIP
e∎Ok/V -s t- l� City State ZIP
Legal Phone Number ✓Legal Fax Nlumber DBA Phone Number DBA Fax Number
iTb3)1D6 3/OO u) --tQL- :3�3`T ( ) - ( ) -
XEmail Address for Notices:
(See"Notices"In the Merchant Card Processing Agreement included with this application for additional information relating to email address usage.)
Customer Service Phone Number I t(S✓)70E2- (c.00 Length Owned:
Website Address...i.k. I► J *, r.-�, v, ►• , ,a i V • Years Months
Preferred Address for
Statements? Li3 Legal Address or❑DBA Address
Chargebacks? legal Address or❑DBA Address y3-FAX'163.7%.*“:37
❑Email Address(TransLink)
XContact Name- � Title Phonee.�
Any prior bankruptcies? Business:❑Yes / If Yes,Filing Date? I Personal:❑Yes(et° If Yes,Filing Date?
Business type: ❑Retail ❑Retell with tips ❑Restaurant MOTOS lritemet5O% ❑Lodging ❑Supermarket ❑Utility ❑Pharmacy
0 Business to Business % Ses`vLGi? ^l'CecreLt,4cto14
Detailed business description(Including description of P oducts or Se Ices sold k ( MCC/SIC
Provide se.arate.ales If needed: • + r, -" y• 6l . ;.., r .
2.W-9 INFORMATION(!nput rnformat:nrr as snow y on yo n nco re ax retort°i
Taxpayer Identification Number;(Must be 9 digits)A t'^fo005 O�ct N ma-:(up tq,40Och�N ) i� e\ t k4
❑EIN or❑Social Security Number �y1 p� fp y�
Address for IRS/Compliance notices:(if different than Legal Address given above) To consent to paperless delivery of IRS notices,please review and check the box below
BYchecking this box,you acknowledge that you have read and agree to Consent to
M`` F Paperless Delivery of Tax Related Documents located at
www.transfirst,com/documents.html and included with this Application and that you
City State ZIP___ consent to receiving IRS notices via papedess delivery.
For purposes of paperless delivery of IRS Notices,you are required to provide a valid email address. If different from the email address already provided above,please indicate the
email address where you wish to receive paperless delivery of your IRS Notices. If you consent to receive!RS/Compliance notices by paperless deliver,please indicate the email
address where such notices should be sent.
(Email address required)
Type of Ownership: Exempt Payee:($(Yes ON()
❑Sole Proprietorship,Date of Birth ❑LLC ❑Partnership 0 Ltd Liability Partnership Ct Govemment Entity ❑Trust ❑Professional Association
❑Political Organization ■ Public Go•oration ✓•Private Co..ration Non Profit Go•.ration
3 OWNER AND OFFICER INFORMATION
NOTE: PRIVACY POLICY WITH RESPECT TO THE COLLECTION AND USE OF SOCIAL SECURITY NUMBERS CAN BE FOUND AT WWW,TRANSFIRST„COM.
Social Security Percent Residential Phone
Nam mee of Owner/Officer and Title Number Owned Residential Address,City,State,Zip Number
• /� -.- a..- - .O u..-
4.i/TRIOT ACT t SITE SURVEY
PATRIOT • ' QUIREMENTS-To help the government fight the funding of terrorism and money laundering activities,the USA Patriot Act requires all final nstitutions to
obtain,verify and - '•formation that identifies each person(including business entities)who opens an account.What this means for you.When yo - -n an account,we will
ask for your name,physics •-. me,date of birth,taxpayer identification number and other information that will allow us to identify you.We ••:,also ask to see your driver's
license or other identifying documen .mplete Section 1 and II for all business types except if a Government Entity where only Sectio. required.Completion of Section III by
Sales Representative is required,
Section is Business Form of Id�nt fication Items ed Section II:Individual Form of • cation Items Reviewed
Business Name: Name:
❑Govt Issued Business License ❑Driver's L'.
Date of Birth:
❑Tax Return Date and Place of Issuance: ri► -r e ID DUlDfk
❑Entity Articles ❑Passpo Date of Issuance:
❑Business Financial Statement ID/IRS Employer •c
❑Military ID State/Country of Issuance:
❑Government Entity
-.•iration Date: .iration Date:
Section III: ❑On Site Visit Do,- ''ales Representative ❑Sales Partner Validated ❑ • -Performed
Merchant's.' cal inventory consistent with the business signage: ❑Yes ❑No Site Consistent with Application: ❑Yes ❑ .
""Signatu. -lesRepresentative: Printed Name: Date:
”? 'rgning above you hereby acknowledge that the information listed herein is true and accurate and was personally observed on the indicated document,as applicable,
Page 1 of 4
v7.1111(CB&T)
5 CARD PROCESSING INFORMATION
X Have you ever accepted credit cards before? u Yes ❑ No If yes,whet is the processor's name? X
x, Please provide the most recent 3 months of credit card processing statements.
% Number of locations? t If you are affiliated with an existing account,please provide existing Merchant ID#:X
❑Please check this box if you are applying for processing services for additional merchant locations. If the additional locations are under common ownership,federal tax
identification number,same authorized signatory,please submit the Additional Merchant Addendum as Exhibit A with this Application.Please note that all additional
locations,along with the Primary location,wit be subject to and governed by the terms and conditions of this Application and the Merchant Card Processing Agreement
referenced in and included with this Application. If the additional locations are not under common ownership or have varying tax identification numbers and authorized
signatories,you will be required to submit a separate Application for Merchant Card Processing per location.
Do you bill your customers prior to goods being shipped? ❑ Yes ❑ No
If Yes,how many days? ❑ 0-2 days ❑P 3-30 days ❑31-60 days ❑61-90 days ❑Over 90 days
What is your Return and Refund Policy?(Please be specific)
l�eA-u►ncA '4/1 SO c� 1.,s/s o r e_SS
How do you advertise?(check all that apply) ❑Yellow pages ❑Telemarketing Q''Catalog liltWord of mouth NTPublications ❑Mass/Direct mail ltemet
❑Other,please explain:
Please supply copies of advertising,including catalogs and brochures.
Where applicable,provkte video(TV),audio tape(Radio or IVR), Web-page screen prints. List the URL(wow.X.can,.net,.org,eta)on each page.
Card Types Requested?"'Select all that apply. At Credit Cards ❑All Credit and PIN Based Debit Cards
"Merchant has the right not to select all card ❑PIN of Based t cards;s;therefore,ref r
g types."Point Of Sale programming cannot prohibit the acceptance of credit cards;therefore,it Is the merchant's
responsibility to enforce this. Processor,and not Merchant Bank,will settle Discover transactions.
Credit Card Processing Methods If the percent of transactions without imprints Average Total Credit/Debit
Card Swiped Transactions % is greater than 20%,do you use a tht_r rty Credit/Debit Monthly Sales
Manually Keyed(Card Present with} ts)sf(1J�Tf/,�ES =% fulfillment house? Oyes MNo Transaction (excludes AMEX):
Manually Keyed(Card Not Present and/or Mail Order/Telephone If yes,whom? (include contact name and (Ticket)Amount
Order) % Phone number) (excludes AMEX):
eCommerce(Card Not Present) % f\ r.
Total(must equal 100%) 100 % $2.00.0() $�O,Ot ,O{J
Seasonal Business?❑Yes o if Yes,indicate by°X"the months that are ACTIVE: ❑Jan❑Feb CJMar❑Apr❑May ❑Jun ❑Jul ❑Aug ❑Sep ❑Oct❑Nov❑Dec
List the names of each of your Independent contractors or agents that will have access to cardholder data,including any third party order-taking service(e.g.,teleservices):
(Provide separate pages if needed)
6 BANKING INFORMATION
Name and Phone Number Routing Number Bank Account Number Type of Accounts Use this account for':
of Financial Institution (Shown on the bottom of check) (Shown on the bottom of check) _te select all that apply)
C) checking settlement
1' ❑ savings thly biting
❑ general ledger chargebacks
2 r. �.-- ❑ checking ❑ daily settlement
❑ savings ❑ monthly billing
❑ general ledger ❑ chargebacks
'If nothing Indicated.Financial Institution#1 will be used for at ACH actWty."AUTHORIZATION FOR AUTOMATIC FUNDS TRANSFER(ACH):The Merchant Bank(cleaned on page t)is autlhorized to Initiate or
transmit automatic debit and/or credt entries andkx check entries to the account identified above and In the provided voided check(if applicable)relating to the above accotnnt("")for all services contemplated
under this Agreement.Said authority is granted to Merchant Bank's Processor and ihet agents.
7 TRADE REFERENCES
Trade Name Account Number Phone Number Product Sold(If applicable)
8 FEE SCHEDULE
PRICING-Select One: ❑QMNRC (N Differential ❑Intg Plus ❑ TransFreedom PROCESSING TYPE: ❑Retail OMOTO ❑TTC
Fee Category-Visa/MC/DISC/
JCBtDiners Cards(If Discount Rate Authorization Fee Per item Fee $Voice.52 Auth Fee Chargeback Fee
applicable) _ _ $ .52 $ 15.00
Qualified or Plus Rate: Al Card Types Batch Close Fee Retrieval Fee
(Retail,MOTO,Internet) 2.99 % $ $ .28 $ 0 $ 15.00
Mid-Qualified Surcharge: AMEX$ Monthly Minimum Application Setup Fee
Retail Only % (if different than above) Discount$ 0 $ 0
Norte Qualified or Differential Pass Dtff+ Month Service Fee
Surcharge' 1.25 $ 9 00 Reprogramming Fee
Retail,MOTO,Internet % TransFreedom Monthly Fee $ 0
$ 0
$
Annual Fee Monthly Merchant Club
Rewards Surcharge:
(Retail Only) ❑ with Qualified Starting Date:
Rewards at Pass Thru $
—,_— ❑ Standard Card
k Card Rebate: Rebates Terminal Support Fee ACH Retum Fee
Check ate:
(Signature k Cardbt: ❑ Card Rebates at
Full Difference $ $ 0 $ 15.00
❑ -
Cross border International transaction assessments)program support,MC network accessrbrand usage(NABU),Visa US acquirer processing fee(APE),Visa Zero Floor Limit,Visa misuse of the aulhonzation
system,MC processing integrity,Discover date usage may appy.Further Visa/MCIDISC mandated fees,including association Base it and kilobyte fees,may also apply.Batch Close Fee:At batch closufg
and belch inquiries are considered'trartsactions'and wit be bated at the same rate as V!MC/Disc Trans Fees unless specified. Monthly Minimum Discount:Applies to Discount Rate&captured
transaction fees. TranaFreedom: Ii addition to your Transfreedom Monthly fee,Automatic Volume Purchase bUtng may apply to volume processed In excess of the current pricing tier at a rate of$20.00 per
every .00 In additional processed volume.
�',.r.ii I'r,au¢),sssn'antrr ifl c:ana(rusr Ints,peuxxLli.Iii mu'�//aor)nl,prca;3;a fs trrd;an'n et nil/trda¢<ti/tna #u,rvs/ni/ar r+,.w;x`w'rtarr P ^ur ttsr{tV£"$ills,Lifjtxruln?..ands q;4in/nL Gn?a;s e43ga;"t ;fEr.tfi+u4., ehn,
I .1tft3,,,ILL cc i.ii"ccL/Jt l t/L.1't.4/?ffA/I/IIJ Ur ttrb.lIk It t nh.Ns.
Page 2 of 4
v7.11it(CBCT)
9 ADDITIONAL SERVICES AND TERMS
❑ ACH Processing(ACH Addendum required) ❑ Check Services(CrossCheck Application required) ❑ Gift Card Services(Tender Card Application required)
PIN DebftEBT
*PIN Based Debit Per Item PIN Based Debit Monthly Fee PIN Based Debit Application Fee EBT Per Item Fee Network Release Fee
Fee $ _. ._.
$ $ $ $ ..,,(semi-annually)
'Debit Discount Rate:NOTE-PIN Based Debit authorization and interchange fees may apply.
Transaction CentraltTransact/on Ex,ress Processln•Services
TC Setup Fee$ (One time per POS) TC Monthly Gateway Fee$ .--^ ' (per POS) Direct Swipe Monthly Fee$
❑TXP Silver ❑ACH I TXP Package Setup Fee$ (per POS) ( TXP Package Monthly Fee$ , (per POS) 1 Integration Fee$
Automated Clearing House(ACH Serv/ces
ACH Application Set Up Fee ACH Monthly Service Fee ACH Rate ACH Per Item Fee ACH Per Return Fraud Check Fee
$ �$ - _ ,. � 1$ _,___. $ $ -_,.•-
WirelessandOtherServices
Wireless Setup Fee(One Time/Per Terminal)$ --' j Wireless Monthly Gateway Fee(Per Terminal)$ . C _..
1:+Monthly e
Other Fee: $ ��-----°°— Other Fee:$ --- '°`"" QuarterlyPCIN•nValidationFee`$2580
�� ,„
OBi-Annually 'Fee will be reduced to$18,80 for ongoing
Description: - — "" Description: Breach Coverage Fee support once compliance is validated
Section 11.2(d)Fee(as stated in the Merchant Card Processing Agreement)does not apply if checked❑ $ 6,95 Fee does not apply if checked❑
American Express(AMEX Fees disclosed in this section are billed by American Express
El Apply For American Express Card Acceptance Have you previously had an American Express SE Number? ❑ Yes ❑ No
AMEX Transaction Fee$ If Yes,American Express SE Number:
❑"American Express Discount Rate Per Item$ ❑Monthly Gross Pay ❑Daily Gross Pay
OR❑ Monthly Flat Fee: $7.95 AMEX Pay Frequency: ❑3-Day ❑15-Day ❑30-Day
CHOSE ONE Of Discount Rata%chosen)
❑Retail$0.10 Trans Fee+0.30%CNP Downgrade OR Annual AMEX Charge Volume$
❑Restaurant$0.05 Trans Fee+0.30%CNP Downgrade OR Average AMEX Ticket $
•Services Wholesale&All Other$0.15 Trans Fee
10, EQUIPMENT OPTIONS
STRY: ❑Retail ❑Retail w/Tips ❑Restaurant ❑MOTO ❑QPS Retail ❑QPS Restaurant ❑Lodging ❑Cash Advance
MEM• SIZE: 0512K ❑lMeg CONNECTION METHOD: ❑Dial 01P/SSL ❑Wireless DIAL PREFIX: SHARED LINE: ❑Yes No
Prompt For oice ❑Yes❑No Prompt For AVS Oyes❑NO Verific.Code Prompt Oyes❑No Corp1Purch Card Oyes Ohio PIN Based Debit es❑No
Auto Close Time: Multi-March ❑Yes(3N0 Parent MID: Number of Child Accounts: Partial A Oyes❑No
EBT Services(select one ❑Cash Benefits only ❑Food Stamps EBT FNS/FCS•(7 digits) ❑Both EBT FNSIFCS#(7'gits)
Mode Version or Equipment billed to:
item Description QTY Code Price**
Number Serial• ❑Merchant ❑Agent • ransFirst ❑N/A
Equipment shipped to:
Terming) $ ❑DBA ❑Legal ❑Agent ❑Other ❑N/A
Terminal $ Welcome Kit sent by:
❑Agent ❑T. First
Printer ❑Thermal $ Welcome Kit shipped to:
❑Roll ❑DBA Y Legal ❑Agent ❑Other ❑N/A
Printer ❑Thermal $ Merchant trained by:
❑Roll ❑Agent ❑TransFirst ❑Other
TXP Integration managed
PIN Pad ❑".ent ❑TransFirst
If"Other"selected a.. e,please provide details below.
Name
PIN Pad $
Check Reader/ $ r- Address
Imager
c n State ZIP
*Software Name $ +,
*Merchant Email Address r•uired:
"'Shipping,handling,and tax will be billed in addition to the equipment price listed above.if merchan wned WAY term I,SIM it&Serial#required.Codes: FU=Free use, :a Merchant owned,PN=
Purchase new,PO=Purchase via other source,PRF=Purchased refurbished,FLS=First Data ='ng,EE=Encryption e:.•ange,RTL=POS Portal rental program or STR=Short term rental.The free use
equipment is the property of TransFirst and Is being provided for free use and Merchant.•• t it has read and agrees to terms and conditions regarding the free use of the equipment as set forth in of
the Merchant Card Processi •A.reemerrt located at d,_..-t_fir t„•s,.•scat: t tut. d included with this A.•iication.
11.TRANSACTION CENTRAL:TRANSACTION EXPRESS I?;ARDWARE AND CONFIGURATION
Product: ■Transaction Central 1111 Transaction tralPlus(CC&ACH-ACH Addendum required) U Transaction Express Silver
Industry Type: 0 Retail 0 MOTO ❑E-Comm:.=e I Web-Site Address(Required):
Email Address(Required):
Integration(Shopping Cart)REGKEY supplied• F:
EQUIPMENT CONFIG QTY CODE PRICE FEATURES* EXTENDED FEATURES*
Pay @PC with/without ❑No swipe Batch Close Method M a ■u C. .1-• h Cards ■: •
Swipe Combo ❑use ❑Serial Recurring Method ❑A OM Duplicate ,d Accept []Y ON
PayFox with/without • •swipe
Swipe Combo 3G 04 Multi-User ❑Y ON ECI(For Intemet) ❑Y ❑N
Printer OUSE ❑Serial Batch Upload ❑Y ON AVS Y
PIN Pad 1000SE ❑use •Serial Allow Blind Credits ❑Y ON PIN-Based Debit w y ON
Pocket March, ❑Stand ❑Spec Private Label ❑Y ON _ Partial Auth L ON
Special In. ctlons: If Y to Private Label,Name:
*Important: If feature not selected,it will be defaulted off. If Manual Recu •is
selected,Auto Recurring is also activated. if both ECI and Recurring needs to be
setup under 1 MID,2 Transaction Central setups are required.
Note:A=Auto I M=Manual I Y=Yes I N•No
Page 3 of 4
v7.1111(CB&T)
Agreement Signature:Each person signing below agrees that they have read and agree to the Merchant Card Processing Agreement terms and conditions which have been
provided to them and certifies that all information provided in this application is true,correct and complete.Each person authorizes the Merchant Bank or any credit bureau or any
credit reporting agency employed by Merchant Bank or any agent of Merchant Bank,to make whatever inquiries the Merchant Bank deems appropriate to investigate,verify or
research references,statements or data obtained from Merchant for the purpose of this application,including requesting reports from consumer reporting agencies on persons
signing below as an owner or general partner of Merchant or as a Guarantor(if such person asks Merchant Bank whether or not a consumer report was requested,Merchant Bank
wit tell such person,and if Merchant Bank received a report,Merchant Bank will give such person the name and address of the agency that furnished it). Each person also
authorizes the Merchant Bank to give information to others,including other creditors and credit reporting agencies,concerning the Merchant Bank experience with Merchant.iff
Merchant does not qualify under our credit guidelines,Processor may share information on Merchant with a third party in an attempt to qualify Merchant The Merchant Bank may
request additional information if the Merchant Bank decides that it is necessary. Credit or other information on the Merchant,owners,officers and any personal guarantors of the
Merchant may be requested for purposes of this Application and during the merchant processing relationship pursuant to Merchant Card Processing Agreement referenced and
included with this Application.
If'RTL'or'STR'is selected,then by signing below,I represent that I have read the POS Portal Rental Agreement and am authorized to sign this application on behalf of the entity
above and all information herein Is true,complete,and accurate.I authorize POS Portal,Inc.("POS Porter)to verify this information and receive and exchange information about
me,Including requesting reports from consumer reporting agencies.By receiving delivery of the POS Portal rental equipment,the entity agrees to be bound by the terms of the POS
Portal Rental Agreement.PLEASE CAREFULLY REVIEW THE TERMS AND CONDITIONS OF VERSION 7.1111 OF THE MERCHANT CARD PROCESSING AGREEMENT
PROVIDED TO YOU AND AVAILABLE AT WWW.TRANSFIRST.COMIDOCUMENTS.HTML,WHICH ARE HEREBY INCORPORATED BY REFERENCE. PLEASE ALSO
CAREFULLY REVIEW,IF APPLICABLE,THE TERMS AND CONDITIONS OF VERSION 2409 OF THE CARD NOT PRESENT ADDENDUM TO THE MERCHANT CARD
PROCESSING AGREEMENT PROVIDED TO YOU AND AVAILABLE AT WWW.TRANSFiRST.COMIDOCUMENTS,HTML, WHICH ARE HEREBY INCORPORATED BY
REFERENCE. BY SIGNING BELOW,(1)YOU ACKNOWLEDGE THAT YOU HAVE READ,UNDERSTOOD AND AGREE TO THOSE TERMS AND CONDITIONS AND(ii)YOU
AGREE TO ACCEPT ELECTRONIC NOTIFICATION OF ANY CHANGES TO THOSE TERMS AND CONDITIONS.PATRIOT ACT REQUIREMENTS-To help the government
fight the funding of terrorism and money laundering activities,the USA Patriot Act requires all financial institutions to obtain,verify and record information that identifies each person
(including business entities)who opens an account What this means for you:When you open an account,we will ask for your name,physical address,date of birth,taxpayer
identification number and other information that will allow us to identify you.We may also ask to see your driver's license or other identifying documents.
If Discover®Network Card acceptance is selected above,Processor will settle your Discover Network transactions and(a)you wit receive one consolidated statement from
Processor that will reflect your Visa,MasterCard and Discover Network transactions;(b)your Discover Network settlement funds will be paid at the same time and in the same
manner as your Visa and MasterCard settlement,(c)you will not have a direct relationship with Discover Network and the terms set forth in the Merchant Card Processing
Agreement for Discover Network transactions will apply;and(d)Merchant Bank(i)does not sponsor Processor into the Discover Network,(ii)is not providing or agreeing to provide
Merchant any services hereunder with respect to Discover Network Card transactions,(iii)does not determine or approve or agree upon any fees,charges,pricing,or any other
terms and conditions,relating to Discover Network Card transactions,and(iv)has no responsibility or liability to Merchant for Discover Network Card transactions. If American
Express is selected above,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 Expresser Card Acceptance Agreement(`Agreement"),and that all information provided herein is true,complete and accurate. I authorize TransFirst and American
Express Travel Related Services Company,inc.("American Express')and American Express'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 agents,subcontractors,
Affiliates,and other parties for any purpose permitted by law. I authorize and direct TransFirst and American Express and American Express's 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 American Express to use the reports from consumer reporting agencies for marketing and administrative purposes, I understand that
upon American Express's approval of the application,the entity will be provided with the Agreement and materials welcoming it to American Express's Card acceptance campaign.
if TransFreedom Program is selected above,then by signing below Merchant acknowledges,accepts and agrees that pricing is based upon processed volume and average ticket
size and that this pricing may be subject to Automatic Volume Purchase billing,in addition to the TransFreedom monthly fee,if Merchants actual processing volume exceeds its
current pricing tier. The Merchant accepts and agrees that it is obligated for all monthly pricing based on its processed volume and average ticket size,including any applicable
Automatic Volume Purchase billing.
If Check Services is selected above,then by signing below,Merchant agrees to be bound by and perform in accordance with all the terms and conditions and provisions of the
Check Services Agreement.Further,Merchant hereby requests Check Service acceptance be added to this Application.Merchant understands that the Terms and Conditions for
Check Service will be sent to Merchant upon approval by Crosscheck.If selected above,Merchant hereby requests Crosscheck acceptance be added to this Application.Further,
Merchant agrees to and accepts all terms and conditions as set forth by CrossChecic If selected above,Merchant hereby requests TenderCard Gift and Loyalty card acceptance be
added to this Application and,Merchant agrees to and accepts all terms and conditions,including,but not limited to any provision for early termination damages as set forth by
Tender Card's Terms and Conditions provided and located at WWW.TRANSFIRST.COM/DOCUMENTS.HTML.By electing to process Credit Card and ACH transactions and by
signing this Application,the Merchant grants consent and authorization to Merchant Bank or its agents or designated representatives to initiate automatic debit and credit entries
end adjustments to the Settlement Account and any Reserve Account through the ACH Settlement Process for the amounts due under the Merchant Card Processing Agreement
in accordance with the terms and conditions of the Merchant Card Processing Agreement,Automated Clearing House(ACH)Addendum and ACH Terms and Conditions provided
and available at WWW.TRANSFIRST.COMIDOCUMENTS.HTML,which are incorporated by this reference. In addition,by signing below the Merchant acknowledges that it has
been•rovided,has read and a•rees to be bound b the ACH Addendum,ACH Terms and Conditions and Merchant Card Processi f Ai reement.
y 12.MERCHANTS)SIGSrIGNATURE(S) , GUARANTOR(S)SIGNATURE(S)
lti
1) �f I�' / 1) .-y-
Merchant Signature(Principal or Owner' D. - Guarantor Signature Date
f}l,I Cf s
xcii-itAtAivelcek> _.-
Print name Title Print name (No Titles)
2) 2)
Merchant Signature(Principal or Owner) Date Guarantor Signature Date
Print name Title Print name (No Titles)
FOR INTERNAL USE ONLY
Signature of Sales Representative:
Accepted by Processor Date Accepted by Merchant Bank Date
8y signing above sales representative hereby admowiedges that the
IMonr anon listed herein Is true and accurate and was personalty
Print name Title Print name TBIe observed on the Indicated document,as applicable.
Page 4 of 4
CARD ORGANIZATION DISCLOSURE PAGE
Merchant Services Provider Contact Information(*=Required)
*Name: Trans First Holdings.Inc.
"'Address: 12202 Airport Way,Suite 100 Broomfield,CO 80021
URL www.TransFirst.com
*Customer Service#: (800)654-9256
*Application Inquiry#: (800)654-9256
*Sales Office#: (800)654-9256
Member Bank/Merchant Bank Information
The Bank's mailing address is Columbus Bank and Trust Company,a division of Synovus Bank,located at 1125 First
Avenue,Columbus,GA,31901,and the phone number is(706)649-4900.
Important Member Bank Responsibilities
• The Bank is the only entity approved to extend acceptance of Payment Network products directly to a Merchant.
• The Bank must be a principal(signer)to the Merchant Card Processing Agreement.
• 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.
• The Bank is responsible for and must provide settlement funds to the Merchant.
• The Bank is responsible for all funds held in reserve that are derived from settlement.
Important Merchant Responsibilities
• Ensure compliance with cardholder data security and storage requirements.
• Maintain fraud and chargebacks below Payment Network thresholds.
• Review and understand the terms of the Merchant Card Processing Agreement.
• Comply with Payment Network rules.
• Retain a signed copy of this Disclosure Page.
• You may download'Visa Regulations"from Visa's website at:
http://usa.visa.com/merchants/operations/op requlations.html
• You may download"MasterCard Regulations"from MasterCard's website at:
hftp://www.mastercard.com/us/merchant/support/rules.html
The responsibilities above do not replace the terms of the Merchant Card Processing Agreement and are provided to ensure
the Merchant understands some important obligations of each party and that the Bank is the ultimate authority should the
Merchant experience any problems.
Merchant Information(*=Required)
*Business Legal Name(Printed): Cr)( IA Clkt A vA\Z:3 t \--k PA B\A:VS
*Business Address: •
SO 41) k\ Av e, t\t, — CrAvotAbkci_ etg\k‘sik\(\
*Business Phone: . . 40 •
X *Signature of Business Principal: ..4/41 PerMAlle
r,v *Printed Name of Business Principal: W 4 L7 f-e
X *Title; " / // '9(V4 6/L
ic *Date: Apkit_ 1 7/ ?°.11eN.
V2.2011
RevTrak, Inc.
December 2011 Merchant Statement
Merchant Information:
MID:
City of Columbia Heights
590 40th Avenue N
NULL
Columbia Heights, MN 55421
*******************************
Daily Deposits
Transaction
Settlement Date Count Amount Other Total
12/1/2011 10 551.33 0.00 551.33
12/2/2011 12 3033.78 0.00 3033.78
12/3/2011 12 2002.68 0.00 2002.68
12/6/2011 12 2948.68 0.00 2948.68
12/7/2011 11 1318.32 0.00 1318.32
12/8/2011 11 1223.50 0.00 1223.50
12/9/2011 13 1751.66 0.00 1751.66
12/10/2011 30 5014.84 -1119.11 Fee-Nov 3895.73
12/13/2011 15 3125.75 0.00 3125.75
12/14/2011 10 1394.97 0.00 1394.97
12/15/2011 13 3605.18 0.00 3605.18
12/16/2011 10 1224.98 0.00 1224.98
12/17/2011 13 2772.46 0.00 2772.46
12/20/2011 5 122.00 0.00 122.00
12/21/2011 9 725.63 0.00 725.63
12/22/2011 11 1226.09 0.00 1226.09
12/23/2011 6 406.06 0.00 406.06
12/28/2011 3 429.62 0.00 429.62
12/29/2011 16 2285.24 0.00 2285.24
12/30/2011 10 173.01 0.00 173.01
12/31/2011 5 831.21 0.00 831.21
Total 237 36166.99 -1119.11 35047.88
*******************************
Transaction Summary
Count Amount
Sales Before Refunds 233 38106.28
Refunds 4 -1939.29
Total-Net Sales 237 36166.99
*******************************
Transaction Fees
Count Amount Fees
Sales @ (1.99%+$0.35) 12 1855.11 41.12
Sales @ (2.59%+$0.35) 172 29102.31 813.95
Sales @ (3.49%+$0.35) 49 7148.86 266.65
Refunds @ (1.99%+$0.35) 4 -1939.29 -37.19
Total 237 36166.99 1084.53
*******************************
Monthly Fees
Qty Amount Total
Account Maintenance Fee 1 19.95 19.95
Total 19.95
*******************************
Fee Totals
Transaction Fees 1084.53
Monthly Fees 19.95
Total Amount Owed 1104.48
RevTrak, Inc.
January 2012 Merchant Statement
Merchant Information:
MID: XXXXXXXXXXXXXXX
City of Columbia Heights
590 40th Avenue N
NULL
Columbia Heights, MN 55421
*******************************
Daily Deposits
Transaction
Settlement Date Count Amount Other Total
1/4/2012 15 2918.51 0.00 2918.51
1/5/2012 24 3291.78 0.00 3291.78
1/6/2012 34 4568.49 0.00 4568.49
1/7/2012 22 2943.95 0.00 2943.95
1/10/2012 23 7208.01 -1104.48 Fee- Dec 6103.53
1/11/2012 31 7376.43 0.00 7376.43
1/12/2012 10 1241.53 0.00 1241.53
1/13/2012 10 1155.08 0.00 1155.08
1/14/2012 14 3556.21 0.00 3556.21
1/18/2012 13 1674.12 0.00 1674.12
1/19/2012 4 662.71 0.00 662.71
1/20/2012 4 562.13 0.00 562.13
1/21/2012 4 778.36 0.00 778.36
1/24/2012 7 1297.58 0.00 1297.58
1/25/2012 9 1174.04 0.00 1174.04
1/26/2012 6 1384.94 0.00 1384.94
1/27/2012 5 413.02 0.00 413.02
1/28/2012 6 1682.16 0.00 1682.16
1/31/2012 10 1789.71 0.00 1789.71
Total 251 45678.76 -1104.48 44574.28
*******************************
Transaction Summary
Count Amount
Sales Before Refunds 250 45878.91
Refunds 1 -200.15
Total - Net Sales 251 45678.76
*******************************
Transaction Fees
Count Amount Fees
Sales @ (1.99%+$0.35) 5 598.54 13.66
Sales @ (2.59%+$0.35) 178 30169.01 843.68
Sales @ (3.49%+$0.35) 67 15111.36 550.84
Refunds @ (1.99%+$0.35) 1 -200.15 -3.63
Total 251 45678.76 1404.55
*******************************
Monthly Fees
City Amount Total
Account Maintenance Fee 1 19.95 19.95
Total 19.95
*******************************
Fee Totals
Transaction Fees 1404.55
Monthly Fees 19.95
Total Amount Owed 1424.50
RevTrak, Inc.
Merchant Statement
February 2012
MID:XXXXXXXXXXXXXXX
City of Columbia Heights
590 40th Avenue N
Columbia Heights, MN 55421
*******************************
Daily Deposits
Transaction Settled
Settlement Date Count Amount Amount Difference Other Notes Total
2/1/2012 8 1058.65 1058.65 0.00 1058.65
2/2/2012 3 976.30 976.30 0.00 976.30
2/3/2012 11 1499.67 1499.67 0.00 1499.67
2/4/2012 11 2086.53 2086.53 0.00 2086.53
2/7/2012 14 1802.45 3604.90* 1802.45 3604.90
2/8/2012 6 1104.92 0.00* -1104.92 0.00
2/9/2012 8 2197.36 2197.36 0.00
2/9/2012 -1424.50 Fee-Jan 772.86
2/10/2012 13 3360.29 3360.29 0.00 3360.29
2/11/2012 28 7060.20 7060.20 0.00 7060.20
2/14/2012 4 910.94 910.94 0.00 910.94
2/15/2012 8 1131.96 1131.96 0.00
2/15/2012 -1802.45* -1802.45
2/15/2012 -1104.92* -1104.92 -1775.41
2/16/2012 18 3442.56 3442.56 0.00 3442.56
2/17/2012 11 1544.74 1544.74 0.00 1544.74
2/18/2012 12 2214.24 2214.24 0.00 2214.24
2/22/2012 10 1012.15 1012.15 0.00 1012.15
2/23/2012 10 1165.35 1165.35 0.00
2/23/2012 2209.84* 2209.84 3375.19
2/24/2012 13 1405.75 1405.75 0.00 1405.75
2/25/2012 13 1058.87 1058.87 0.00 1058.87
2/28/2012 12 1256.39 1256.39 0.00 1256.39
2/29/2012 9 878.22 878.22 0.00 878.22
Total 222 37167.54 37167.54 0.00 -1424.50
* For further detail,see attached reconciliation statement.
*******************************
Transaction Summary
Count Amount
Sales Before Refunds 220 37275.54
Refunds 2 -108.00
Total - Net Sales 222 37167.54
*******************************
Transaction Fees
Count Amount Fees
Sales @ (1.99%+$0.35) 9 1501.44 33.03
Sales @ (2.59%+$0.35) 167 29868.71 832.05
Sales @ (3.49%+$0.35) 44 5905.39 221.50
Refunds @ (1.99%+$0.35) 2 -108.00 -1.45
Total 222 37167.54 1085.13
*******************************
Monthly Fees
Qty Amount Total
Account Maintenance Fee 1 19.95 19.95
Total 19.95
*******************************
Fee Totals
Transaction Fees 1085.13
Monthly Fees 19.95
Total Amount Owed 1105.08
CITY OF COLUMBIA HEIGHTS
Walter R. Fehst
City Manager
590 -40th Avenue N.E.
Columbia Heights,MN 55421
5"y' (763)706-3610
FAX(763)706-3601
email:walt.fehst@ci.columbia-heights.mn.us
SBSI
16598 Iredale Court, Lakeville, MN 55044-4511
Phone: 952.435.4080 or 800-434-8301 Fax: 952.435.5859
E-Mail: sales@sbsiinc.com
Web Site: www.sbsiinc.com
eMail (with PDF) TRANSMISSION
TO: Joe Kloiber
eMail:joseph.kloiber@ci.columbia-heights.mn.us
FROM: Fred Gedelman
DATE: February 24, 2012
PAGES: 7
SUBJECT: Application For Merchant Card Processing
MESSAGE: Attached is the "Application For Merchant Card Processing" (5 pages) to
apply for a Merchant ID #that will be used for processing debit and credit cards through your
new eClassTrak Software for student registration.
Please complete this 'Application' where it is marked with an "X". The person signing this
Application should be someone who also has check signing responsibilities.
When you PDF - Preferable (or Fax) your 'Application' back to us please include the
following:
1. PDF (or Fax) copy of a voided check from the account where the credit card charges
will be deposited. If you don't use checks, please have your bank write us a letter like
the sample letter attached.
2. PDF (or Fax) copy of the last(3) months Credit Card Statements from your bank.
3. PDF (or Fax) copy of a business card from the person signing this 'Application'.
Please PDF (or Fax) the above items with your 'Application' to both eMail addresses (or
Fax numbers) below:
Brent Kauth (Credit Card Processor) Fred k de an
Advanced Payment Technologies SBSI So are, Inc.
Fax: 952.922.7629 Fax: 95 .4 5859
bkauthedutrak.com fgedel anAs iinc corn
It usually takes 1 - 2 weeks for approval after we have received your 'Application' and
support materials.
Thank you for your time! If you have any questions, please call us at: 1.800.434.8301.
Information Systems
City of Columbia Heights
Financial Reporting
Accounts Payable ,
Utility Billing
Finance Department Payroll
590 40th Avenue N.E. Columbia Heights,MN 55421-3878 Office(763)706-3600 TDD(763)706-3692 Fax(763)706-3637
FAX TRANSMITTAL
4/17/2012
FROM: Joseph Kloiber, Finance Director
City Of Columbia Heights MN
TEL: 763-706-3627
FAX: 763-706-3637
Email: joseph.kloiberci.columbia-heights.mn.us
TO: Brent Kauth
Advanced Payment Technologies
FAX: 952-922-7629
Email: bkauthedutrak.com
Total number of pages transmitted, including this cover page is 1.
Message: The information below is to complete section 6 of the "Application for
Merchant Processing" emailed to you today:
Bank Name: Wells Fargo
Bank Phone: 612-316-3284
Bank Routing Number: -
Bank Account Number:
Service Is Our Business
THE CITY OF COLUMBIA HEIGHTS DOES NOT DISCRIMINATE ON THE BASIS OF DISABILITY IN EMPLOYMENT OR THE PROVISION OF SERVICES
EQUAL OPPORTUNITY EMPLOYER
TRANSMISSION VERIFICATION REPORT
TIME : 04/17/2012 14:47
NAME : COLUMBIAHGTS-FINANCE
FAX : 7637063637
TEL : 7637063637
SER.# : 000L7N262519
DATE TIME 04/17 14:46
FAX NO./NAME 99529227529
DURATION 00:00:29
PAGE(S) 01
RESULT OK
MODE STANDARD
ECM
Ft
'7 a
371 Centennial Pkwy, Louisville, CO 80027
Merchant Change Form
Merchant ID#: 3230043869 Short Name: APT
Check all that apply:
❑ADDRESS CHANGE ❑NAME CHANGE ❑ACH CHANGE*$15.00 FEE
ORATE CHANGE. Effective Date**: ❑REACTIVATION*$10.00 FEE(voided check required)
**(IF NO DATE LISTED, WILL ASSUME THE 15T OF THE FOLLOWING MONTH) To correct Skipjack is not merchant owned
Legal Bus. Name of Applicant DBA Name City of Columbia Heights
Mailing Address Physical Address 590 40th Avenue NE
(No PO Boxes)
City State Zip City Columbia Heights State MN Zip 55420
Phone( ) Fax( ) Phone(763)706-3600 Fax(763) 706-3637
E-Mail Address: Contact Name Joseph Kober Business Hours
Fed. Tax ID#(EIN) 41-6005069 Length Owned 704"Years Months Seasonal? ❑ Yes Months Open
Type of entity: ❑Proprietorship ❑ Corporation ❑ LLC ❑ Gen Partnership ❑ Ltd. Partnership ❑ Other
AUTHORIZATION FOR AUTOMATIC FUNDS TRANSFER (ACH): The Merchant Bank is authorized to initiate or transmit
automatic credit and/or debit entries to the account identified in the attached voided check relating to the following account:
BANK NAME ROUTING# ACCT#
(ATTACH A VOIDED CHECK)
PRICING(List only those fees that are changing and/or being added)
Discount Rate% Per Item$ ❑ Retail ❑MOPO ❑TTC Monthly Minimum Discount$
❑ 100%Interchange and Assessments ❑ 100%Interchange(No Assessments) Monthly service fee$ Start Date
Network trans V/MC/DINERS/JCB/FLEET$ Network trans V/MC/DISC$ Network trans AMEX$
Voice Auth$ ARU Auth$ Monthly service fee$
Non-Qualified Surcharges: All Visa/MasterCard/Discover interchange downgrades are passed thru. Cross border international transaction
assessments/program support,MC network access/brand usage(NABU),Visa US acquirer processing fee(APF)and card association base II and kilobyte
fees may apply.
❑Non-Qualified Surcharge Differential+ ❑ with Qualified Rewards at pass thru and Check Card Rebates at Full difference
❑Non-Qualified Mid/Non Mid %Non % ❑ with Qualified Rewards at pass thru and Check Card Rebates at
Miscellaneous Ferss'ill APT $225 setup fee and Bill APT $30 Monthly Skipjack Fee
PIN-Debit Per Item Fee$ PIN-Debit Monthly Fee$ PIN-Debit Application Fee$ EBT Per Item Fee$
Transaction Central(TC)Set-up Fee$ TC Monthly Fee$ TC Plus Per Item Fee$
Wireless Set-up Fee$ Wireless Monthly Fee$ Other$
AMEX Fees disclosed in the section below are billed by American Express
American Express(AMEX)Discount Rate %or Monthly Flat Fee$ ❑Monthly Gross Pay ❑ Daily Gross
Pay
Retail$0.10 Trans Fee+.30%CNP Downgrade OR ❑Services,Wholesale and All other$0.15 trans fee
Amex Pay Frequency ❑3-Day ❑5-Day ❑30-Day Annual AMEX Charge Volume$ Avg AMEX Ticket$
The undersigned certify and affirm, under penalty of perjury,that all changes and/or instructions contained herein have been fully authorized
and approved by the Board of Directors or other managing body or person of the Merchant.
SIGNATURES
Merchant Signature /Z-----7/
°'"r T ' Date 5 e
Print Name
l /G- � w �' 5 I 6 / i/ ,94/ Ce,
Guarantor Date
TransFirst Use Only: Completed By/Date: /