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New merchantapplication

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  • 1. MERCHANT APPLICATION Electronic Payment Systems, LLC Englewood, Colorado 80111 NO CANCELLATION FEES Merrick Bank, South Jordan, Utah O ce No. Agent NameAPPLYING FORInitials X Initials XBUSINESS NAME(S)Name of Account (doing business as) Exact Legal NamePhysical Street Address Mailing / Billing Address (if di erent from mailing address)City State Zip City State ZipBusiness Phone No. ( ) Cell ( ) E-mail AddressMerchandise / Service Sold Federal Tax ID No.MERCHANT PROFILE VISA, MASTERCARD, & DISCOVER NETWORK INFORMATIONYour Company’s Website Address www. Do You Currently Accept Visa, MasterCard, and/or Discover Network? Yes NoType of Ownership Sole Proprietor Partnership Corporation LLC Other if yes, please submit 3 current months of statements.Date Business Started Length of Current Ownership Current / Previous Card ProcessorHas This Business or Any Associated Principal Been Terminated as a Visa, MasterCard, Discover Network Reason for LeavingMerchant? Yes No Card Swipe + % Average TicketHas Merchant or any Associated Principal Disclosed Below Filled Bankruptcy or Been Subject to Involuntary Manually Keyed + % Low TicketBankruptcy? Yes Date No Mail Order + % High TicketPrevious Owner Telephone Order + % Average Monthly Volume Total = 100 % High Monthly VolumeOWNERS OR OFFICERSName Title Name TitleSocial Security No. Date of Birth Social Security No. Date of BirthResidence Address Residence AddressCity State Zip Home Phone No. ( ) City State Zip Home Phone No. ( )Equity Ownership % Excellent Good No Credit History or Derogatory Info Equity Ownership % Excellent Good No Credit History or Derogatory InfoREFERENCESTrade Reference Contact Phone No.Trade Reference Contact Phone No.Bank Reference Contact Phone No.MERCHANT SITE SURVEY REPORT (TO BE COMPLETED BY SALES REPRESENTATIVE)Merchant Location Retail With Store Front O ce Building Residence Other The Business Premises is Owned by Merchant LeasedArea Zoned Commercial Industrial Residential If Leased From Whom Name Phone No.Nearest Major Cross Streets Square Footage 0-250 251-500 501-2,000 2,001+Further Comments by Inspector (MUST COMPLETE) Does the Amount of Inventory and Merchandise on Shelves and Floor Appear Consistent with the Type of Business? Yes No if no, explainI hereby verify that this application has been fully completed by the merchant and that I have physically inspected the business premises of the merchant at this address and the information stated above is true and correct to the best of my knowledge and belief.Agent Name (please print) Signature Agent No. Date
  • 2. MERCHANT APPLICATION PROCESSING AGREEMENT (Continued) VOIDED CHECK FROM CHECKING ACCOUNT MUST BE ATTACHED (DO NOT USE A DEPOSIT OR STARTER CHECK) ELECTRONIC DEBIT / CREDIT AUTHORIZATION Merchant hereby authorizes Bank, in accordance with this Agreement, to initiate debit/credit entries to Merchant’s deposit account, as indicated below. This authority is to remain in full force and e ect until (a) Bank has received written noti cation from Merchant of its termination, in such a manner as to a ord Bank reasonable opportunity to act on it and (b) all obligations of Merchant to Bank that have arisen under this Agreement have been paid in full. This authorization extends, but is not limited, to such entries to this account which concern discount fees, transaction fees, chargebacks, penalties, service fees, return item fees, lease, rental and purchase charges, check services, warranty services, Internet services or other services o ered by EPS, involving Poin-Of-Sale(”POS”) and credit card imprint equipment. PRICING SCHEDULE A NO CANCELLATION FEES CARD DISCOUNT % OFFLINE DEBIT % Debit Authorization Fee AMEX Yes AUTH. FEE RETAIL MOTO ACH Rejection $25.00 1 1 AMEX Merchant I.D. MasterCard $0.25 $0.35 Charge Back Fee $25.00 2 2 Annual Fee $85.00 Visa $0.25 $0.35 Administration Fee $10.00 Discover Network $0.25 $0.35 Minimum Discount Fee $25.00 3 3 FMP Warranty Yes $8.95/mo. (includes Free repair/replacement) Other $0.25 $0.35 Wireless Fee $25.00 4 4 Wireless $0.15 $0.15 Voice Authorization $0.95 AVS $0.04 $0.04 Retrieval Fee $12.00 5 5 SIC Code Checking Account Change $20.00 See Speci c Documentation for Fees. Internet Gateway $10.00 (Surcharge of up to 1.75% applied to all transactions Voice Auth. Setup $4.95 which fail to qualify for Visa MasterCard electronic data RETAIL MOTO BUNDLED RATE capture interchange requirements.) EPS 90 PRICING SCHEDULE A Registration and Encryption Fee of $320.00 is due at signing. PRICING TO MERCHANT SHALL BE AS FOLLOWS: SERVICE REQUESTED: % per check Trans. Fee Admin. Fee Monthly Minimum Conversion With Guarantee $0.25 $10.00 $25.00 Single Check Conversion With Guarantee (one check for full payment not post dated) $0.25 MUST ACCOMPANY CONVERSION WITH GUARANTEE SERVICE An account set-up fee of $25.00 will be debited from the rst check in the series when multiple checks are used in a single transaction. Fee payment not otherwise covered in this Agreement shall be debited from Merchants’ account on or about the 5th of each month for activity in the prior calendar month. An annual Fee of $85.00 is billed each year in December regardless of time of enrolment and cannot be waived or refunded.License Fee: When applicable, in consideration for the granting of the license and the use of the Software, Licensee agrees to pay Developer a recurring monthly gateway fee of $19.95 ofr the term of this agreement and any subsequent renewals. EPS 90 INFORMATION STANDARD TICKET AMOUNTS: TERMINAL/CHECK READER TYPE: FMP WARRANTY: Average Low High Terminal Model For 1 Terminal ($8.95) Reader Model For 2 Terminals (14.95) PCI-DSS DATA Does Merchant Use an Independent Servicer That Stores, Maintains, or Transmits Cardholder Information No Yes IF YES PLEASE PROVIDE: Name Phone No. Product or Service Being O ered Does the Merchant use Software Terminal If Software, What is the Payment Application Name What Version of the Payment Application is in Use If Terminal, What TypeX X Signature Printed Name Date Signature Printed Name Date PERSONAL GUARANTEE The undersigned personally, and in his or her capacity of and for any named entity he/she represent, unconditionally guarantees the Bank and Electronic Payment Systems, LLC (EPS) the performance of this Agreement including by not limited to: payment of all sums due and owing; adherence to all terms and conditions of this agreement and any attachments hereto; and agrees to pay any attorneys fees and costs associated with enforcement of the terms, conditions, and agreements contained herein. Bank and/or EPS shall not be required to rst proceed against Merchant for enforce or see any other remedy before proceeding against the undersigned. This is a continuing guaranty and shall not be discharged or a ected by the death or the undersigned, shall bind the heirs, administrators, representatives and assigns and may be enforced by or for the bene t of any successor of Bank or EPS. The terms of this guaranty shall be for the duration of the Merchant Processing Agreement and all attachments thereto and shall guarantee all obligations which may arise or accrue during the terms thereof. Enforcement may be sought subsequent to any termination.X X Personal Guarantor (No Title) Personal Guarantor (No Title) The undersigned personally, and in his or her capacity of and for any named entity herein represents and warrants that all information provided by Merchant in the Merchant Application and Processing Agreement, and if elected as a service, the EPS 90 Application and Purchase Agreement, and any other documents thereto, is true and correct. Also, the undersigned authorizes the Bank an/or EPS or its representative to investigate the credit of each person and/or entity listed on the Merchant Application and represents that he/she has the authority to provide such information. MERCHANT HEREBY AGREES AND ACCEPTS ALL TERMS AND CONDITIONS CONTAINED HEREIN AND OUTLINED IN THE ARTICLES 1.01 THRU 3.14(K) RESPECTIVELY FOR THE MERCHANT PROCESSING AGREEMENT, AND IF ELECTED AS A SERVICE, ARTICLES 1 THRU 8 RESPECTIVELY OF THE ARTICLES, TERMS AND CONDITIONS OF THE EPS 90 APPLICATION AND PURCHASE AGREEMENT. FURTHERMORE, MERCHANT ACKNOWLEDGES RECEIPT OF A PHYSICAL COPY OF THIS AGREEMENT WHICH CONTAINS THE AFOREMENTIONED ARTICLES AND OTHER TERMS AND CONDITIONS THAT GOVERN THIS AGREEMENT.X X Signature Printed Name Date Signature Printed Name Date Accepted by Merrick Bank * Agent Relations * South Jordan, UT 84095 * 303.221.2510 Accepted by Electronic Payment Systems,LLC * Englewood, CO 80111 * 800.863.5995 By Title By Title
  • 3. In consideration of the mutual covenants and agreements herein Merrick Bank ("Acquirer"), Electronic Payment Systems ("EPS") acting on behalf of and for (c) in connection with a recurring transaction (or preauthorized order) pursuant to which goods or services are delivered to or performed for a cardholderAcquirer and the undersigned merchant ("Merchant") have agreed as follows as of the date of acceptance by Acquirer and issuance of a valid merchant number: periodically. Merchant agrees to the following conditions (i) Merchant must obtain a written request from the cardholder that the recurring transaction be charged to the cardholders account.ARTICLE 1 CARD TRANSACTIONS (ii) the written request must specify the amount of the recurring transaction (or allow space for cardholder to specify a minimum and maximum amount if the recurring transactions are to be for varying amounts), the frequency of the recurring charges, and the length of time for which the preauthorized order is to remain1.01 Honoring Integrated Card Solution in e ect.(a) Merchant shall honor without discrimination all valid cards of the type(s) made available for processing by EPS when properly presented as payment by (iii) before renewing a preauthorized order, Merchant must obtain a subsequent written request from the cardholder containing the information listed abovecustomers in connection with bona de, legitimate business transactions. If Merchant does not deal with the public at large (such as in the case of a private club), (iv) Merchant must retain the cardholders written authorization for as long as the preauthorized order is in e ect and must provide a copy to Acquirer uponMerchant shall be deemed to have complied with this non-discrimination rule if it honors all valid Integrated Card Solution of cardholders who have purchasing request.privileges or memberships with Merchant. (v) Merchant must not deliver goods or perform services covered by a preauthorization order after being advised that the preauthorization has been canceled(b) Merchant shall not require, through an increase in price or otherwise, any cardholder to pay any surcharge at the time of sale or to pay any part of any charge or that the Card is not to be honored, andimposed on Merchant by Acquirer (Discounts for payment in cash, however, are permitted). (vi) Except as provided in Section 1.07, a recurring transaction may not include partial payments to Merchant for goods or services purchased in a single(c) Merchant shall not establish minimum or maximum transaction amounts. transaction, or for periodic payments of goods or services on which Merchant assesses additional nance charges.(d) Merchant shall not require a cardholder to provide identi cation information such as telephone number, address or drivers license number as a condition of (vii) Merchant must inform cardholder that he has the right to receive, at least 10 days prior to each scheduled transaction date, written notice of the amountcompleting a transaction, unless such identi cation is required by MasterCard International, Inc. ("MasterCard"), Visa U.S.A. Inc. ("Visa"), Discover ® Network rules and date of the next charge. Cardholder may elect to receive the noticeand regulations and is permitted by the law of the state in which the transaction takes place, for example, in mail order transactions. (A) for every change(e) Merchant may not make a photocopy of a card under any circumstances and may not request that the cardholder provide a photocopy of the card as a (B) only when the transaction amount does not fall within the speci ed range shown on the order form, orcondition for honoring the card. (C) only when the transaction amount will di er from the most recent charge by more than an agreed upon amount.1.02 Advertising (d) Merchant may o er cardholders an installment payment option for its mail/telephone order merchandise subject to the following conditions(a) Merchant shall display adequately any advertising or promotional material provided or required by Acquirer to inform the public that Integrated Card Solutions (i) Merchants promotional material must clearly disclose the installment terms including but not limited towill be honored at Merchants place of business. Such displays, however, are not required of private clubs and other Merchants that do not deal with the general (A) whether the plan is available only for selected items or for the total amount of any order andpublic, vehicle leasing companies at airport locations, transportation companies subject to government regulation, or other Merchants expressly exempted from (B) how shipping and handling charges and applicable taxes will be billed. The material also must advise cardholders who are not billed in the transactionthis requirement by MasterCard, Visa, and/or Discover Network as applicable. currency of the Merchant that the installment billing amounts may vary due to uctuations in the currency conversion rates(b) Merchant shall not display or use advertising or promotional materials containing Acquirers name or symbol which might cause a customer to assume that (ii) No nance charges may be added by Merchant. The sum of the installment transactions may not exceed the total sales price of the merchandise on a singleMerchant honors only Cards issued by Acquirer. transaction basis(c) Merchant shall have the right to use or display the proprietary names and symbols associated with Integrated Card Solution only while this Agreement is in (iii) Authorization is required for each installment transaction. Merchants oor limit is zeroe ect or until Merchant is noti ed by Acquirer or any appropriate Integrated Card Solution organization to cease such usage. (iv) Merchant may not deposit the rst installment transaction with Acquirer until the merchandise is shipped. Subsequent installment transactions must be(d) Merchant shall comply with all applicable MasterCard, Visa, and Discover Network rules and regulations concerning the use of service marks and copyrights deposited.owned by MasterCard, Visa, and or Discover Network. (A) at intervals of 30 days or more, or(e) Merchant shall use the proprietary names and symbols associated with Integrated Card Solution only to indicate that Cards are accepted for payment and shall (B) on the anniversary date of the transaction (i.e. the same date each month)not indicate, directly or indirectly, that Acquirer. MasterCard, Visa, or any Integrated Card Solution organization endorses Merchants products or services. (v) in addition to Merchants name, an appropriate installment transaction descriptor (e.g. one of ve, two of ve) must be included in the Merchant name eld(f) Merchant shall not refer to MasterCard, Visa, or Discover Network in stating eligibility for its products, services or memberships. of the clearing record.1.03 Card Examination (e) An imprint of the card is required whenever card is present.(a) Merchant agrees to con rm that user is cardholder. 1.09 Vehicle Rental Transactions(b) Merchant agrees to examine any card security features (such as hologram) included on the Card. Merchant shall compare the embossed account number on Regardless of the terms and conditions of any written preauthorization form, the sales slip amount for any vehicle rental transaction shall include only that portionthe face of the Card with the account number indent on the signature panel. of the transaction, including any applicable taxes, evidencing a bona de renting of personal property by Merchant to a customer and shall not include any(c) Merchant shall, prior to completing the transaction, check the validity date and expiration date of the Card and shall not honor any Card that is not valid or that consequential charges. Nothing herein is intended to restrict Merchant from enforcing the terms and conditions of its preauthorization form through means otherhas expired, without proper authorization. than a Card transaction.(d) Where the magnetic stripe on the Card is read in connection with a transaction, Merchant shall compare the embossed account number on the Card to the 1.10 Returns and Adjustments, Credit Slipsnumber displayed or printed by the terminal to ascertain that they are the same. (a) If with respect to any transaction, any merchandise is accepted for return or any services are terminated or canceled, or any price adjustment is allowed by the(e) Except in connection with a mail order, telephone order or pre-authorized transaction, Merchant shall not complete a transaction without presentation of the Merchant (other than involuntary refunds by airlines or other carriers when required by applicable tari s and except where otherwise required by law orCard by the cardholder and a proper examination by the Merchant of the Card. governmental regulations) Merchant shall not make any cash refund to the cardholder but shall deliver promptly to Acquirer a credit slip evidencing such refund(f) If the signature panel on the card is blank, Merchant shall: or adjustments. (i) review positive identi cation to determine that user is cardholder. Such identi cation must consist of a current o cial government identi cation document (b) Each credit slip shall be signed and dated by Merchant and include the transaction date, a description of the goods returned, services canceled or adjustment(such as a passport or drivers license) that bears the cardholders signature; and made and the amount of the credit in su cient detail to identify the transaction and the embossed data from the Card and Merchants imprinter plate. (ii) indicate such positive identi cation (including any serial numbers and expiration date) on the sales draft if the transaction is a Visa transaction, and if (c) The refund or adjustment shall be indicated on a credit slip and may not exceed the original transaction amountpermitted by law. (Such information shall not be recorded for MasterCard transactions); and (d) The Merchant may limit its return, adjustment, refund or exchange policies provided that proper disclosure is made and purchased goods or services are (iii) require cardholder to sign the signature panel before completing the transaction; and delivered to the cardholder at the time of the transaction. (iv) request authorization. (e) Proper disclosure by the Merchant must be given at the time of the transaction by printing the following words or similar wording on all copies of the sales slip(g) In the case of a Visa card, Merchant shall compare the printed issuing bank identi cation number, which is directly above the rst four digits of the embossed or invoice being presented to the cardholder for signature in letters approximately 1.4 inch high and in close proximity to the space provided for the cardholdersaccount number. If the printed number and the embossed number do not match, Merchant shall call the voice authorization number and request a Code 10 signatureoperator. (i) "NO REFUND" For a Merchant which may not accept merchandise in return or exchange and may not issue a refund to a cardholder.1.04 Authorization (ii) "EXCHANGE ONLY" For a Merchant which may only accept merchandise in immediate exchange for similar merchandise of a price equal to the amount of the(a) Before honoring any Card, Merchant shall request authorization from Acquirers designated authorization center. original transaction.(b) Authorization numbers or positive account number veri cation response codes, as appropriate, shall be printed legibly in the designated area on the sales slip. (iii) "IN-STORE CREDIT ONLY" For a Merchant which may accept merchandise in return and deliver to the cardholder an in-store credit for the full value of the(c) If authorization is denied, Merchant shall not complete the transaction and shall use its best e orts by reasonable and peaceful means to follow any merchandise returned which may be used only in the Merchants place(s) of business.instructions from the authorization center. (iv) A Merchant may, if permitted by applicable law, stipulate special circumstances agreed to by the cardholder (e.g. late delivery, delivery charges or insurance(d) Merchant shall be liable to Acquirer, regardless of any authorization, if Merchant completes a transaction when the cardholder is present but does not have his charge(s) as terms of the transaction, but under no circumstance shall a surcharge be assessed for the use of a Card. The wording to appear on the sales slip shallCard, the cardholder does not sign the sales slip, or the signature on the sales slip does not match the signature appearing on the Card or the signature panel on be any special terms of the transaction(s).the card is blank. (f) Merchant must deliver to the cardholder a true and complete copy of the credit slip at the time of the credit transaction. Merchant shall not process a credit slip(e) In no event shall an authorization be deemed to be Acquirers representation that the particular transaction is in fact a valid, authorized or undisputed without having completed the purchase transaction with the cardholder. In no event may the credit exceed the amount of the original transaction.transaction entered into by the cardholder or an authorized user of the Card. 1.11 Cash Payments, Factoring, Split Sales(f) Where authorization is requested for a transaction involving suspicious or unusual circumstances the Merchant shall call and request a "Code 10" authorization (a) Merchant shall not receive any payments from a customer for charges included on any transaction record resulting from the use of any Card, nor receive anyfrom Acquirers designated authorization center. payments from a cardholder to prepare and present a credit slip for the purpose or e ecting a deposit to the cardholders account.(g) An authorization for a restaurant transaction in which a gratuity is added to the sales slip by the cardholder is valid if the total transaction amount is within 20% (b) Factoring is the act of processing a transaction that is not the result of goods or services provided or sold by the Merchant and for the bene t of others. Thisof the authorization amount. includes any transaction that may generate a fee to Merchant for this service. These and any like transactions are PROHIBITED under this agreement.(h) If authorization is obtained for the estimated amount of a car rental transaction, Merchant shall disclose to cardholder such amount authorized on the rental (c) Split Sales are transactions that utilize the same card, at the same time in incremental amounts to achieve a desired authorization amount. If one card is used itdate. must be for the full amount of the sale. This does not apply to Installment Orders as described in 1.08 above.(i) Merchant acknowledges that EPS and/or Bank will monitor Merchants daily deposit activity. The deposit activity should remain consistent to the "approved" 1.12 Cash Advancesmonthly volume and average ticket amount approved on the Merchant Agreement and Application. If the Merchant should exceed the "approved" monthly Merchant agrees not to make any cash advance to a cardholder or take any cash advances for themselves, their employees, family members or their company,volume, the Merchant acknowledges that additional documentation could be required. Merchant agrees that Bank may upon reasonable grounds suspend the either directly or by deposit to the cardholders account. Money orders sent by wire, contribution to charitable and political organizations, tax payments, insurancedisbursement of Merchants funds for any reasonable period of time required to investigate suspicious or unusual deposit activity. EPS and/or Bank will make good premium payments for (1) one quarter year or less, alimony and child support payments, and court costs and nes shall not be considered cash advances orfaith e orts to notify Merchant immediately. EPS and/or Bank shall have no liability for any losses, either direct or indirect, which Merchant may attribute to any withdrawals.suspension of funds disbursement. 1.13 Transactions Acceptable Under This Agreement(j) In all cases the nal delivery and/or performance of all goods and/or services shall not exceed ninety (90) days from the date of the original transaction. Notwithstanding any other Sections, conditions, covenants or requirements contained herein, Merchant is approved to accept transactions, as outlined in this1.05 Retention and Retrieval of Cards agreement in the normal course of Merchants business that are germane to Merchants business and within the "approved" average ticket and volumes forMerchant shall use its best e orts, by reasonable and peaceful means, to retain or recover a Card Merchant. Transactions should be within the reasonable context of the information provided by Merchant at the time of Application and conform to the standards(a) If Merchant receives a negative response from the account number veri cation service and until Merchant receives further instruction from Acquirers established by S. I. C. (Standard Industry Code) that identi es their business.designated authorization center. 1.14 Disclosure and Storage or Cardholder Account Information(b) While making an authorization request. (a) Except as otherwise required by law, Merchant shall not, without the cardholders prior written consent, sell, purchase, provide, or otherwise disclose the(c) If Merchant is advised to retain the Card in response to an authorization request, or cardholders account information or other cardholder information to any third party other than Acquirer.(d) Where the embossed account number, indent printed account number, and/or encoded account number do not match or an unexpired Card does not have (b) Merchant and/or any agent of Merchant shall store in an area limited to selected personnel and, prior to discarding, shall destroy in a manner rendering datathe appropriate hologram on the Card face, or unreadable, all material containing cardholder account numbers including but not limited to card imprints, such as sales slips and credit slips, car rental(e) If the Merchant has reasonable grounds to believe the Card is counterfeit, fraudulent or stolen agreements and carbons.(f) The obligation of Merchant to retain or recover a Card imposed by this section does not authorize a breach of the peace or any injury to persons or property, (c) Merchant or any agent of Merchant shall not retain or store magnetic stripe data subsequent to the authorization of a transaction.and Merchant will hold Acquirer harmless from any claim arising from any injury to person or property or other breach of the peace. (d) Merchant will be responsible for maintaining all records of all transactions including but not limited to: original sales slips, signed sales drafts, signed credit(g) If a recovered card is retained by a law enforcement agency Merchant shall forward a legible copy of the front and back of the card to Acquirer, or other drafts, work orders, or any other document that pertains to the sales for which a credit card was used as a form of or partial payment of the subject transaction forIntegrated Card Solution organization as appropriate to support payment of any applicable reward. a minimum of thirty-six (36) months from the date of the original transaction.1.06 Completing the Transaction Record 1.15 DepositsExcept as provided below, Merchant agrees to do all or the following when honoring a Card. Notwithstanding any other Sections, conditions, covenants or requirements herein, Merchant may accept deposits for goods and/or services to be performed in a(a) To enter on the sales slip the transaction date, a description of the goods or services sold, and the price thereof (including any applicable taxes) in detail timely manner. A deposit shall not be used as a payment to Merchant and is not to be used as interim nancing or a “Cash Advance” as outlined in 1.12 above.su cient to identify the transaction. Deposits, when identi ed by Acquirer, may be held in a reserve account until satisfactory completion of services and/or delivery of good can be veri ed.(b) To obtain the signature of the customer on the sales slip after the transaction amount is identi ed in the Total column.(c) To compare the signature on the sales slip and the signature panel of the Card and if the Card has a photograph of the cardholder to ascertain that the ARTICLE II PRESENTMENT PAYMENT AND CHARGE BACKcustomer resembles the person depicted in the photograph, and if either identi cation is uncertain, or the account numbers are not the same or Merchantotherwise questions the validity of the Card, to contact Acquirers authorization center for instructions. 2.01 Presentment of Transaction Records to Acquirer(d) To Imprint legibly on the sales slip the embossed legends from the Card and from the merchant imprinter plate. If the imprinter does not legibly imprint the (a) Merchant may designate a third party (that does not have a direct agreement with Acquirer) as its agent for the purpose of delivering transactionsembossed legends from the Card and Merchant plate. Merchant shall detail legibly the cardholders name and account number and Merchants name and place of data-captured at the point of sale by such agent if Merchant elects to use such third party as its agent for the direct delivery of data-captured transactions.business, as well as the name or trade style of the issuer as it appears on the face of the Card, the ICA number, the Card initials, if any, and both the e ective date Merchant agrees to the following conditions (for the purposes of this section 2.02, "Merchant" includes any agent designated by Merchant as permitted under thisand expiration date. Merchant shall also record on the sales slip any other embossed data such as security symbols. section):(e) To deliver a true and completed copy of the sales slip to the customer at the time of delivery of the goods or performance of the services or for point of (i) Merchant must provide satisfactory notice to Acquirer that Merchant chooses to exercise the option speci ed above;transaction terminal transactions, at the time of the transaction. (ii) The obligation of Acquirer to reimburse Merchant for transactions is limited to the amount (less the appropriate discount fee) delivered by Merchants(f) For transactions which originate at and are data captured using point-of-transaction terminals. Merchant must include the following information on the designated agent, andcardholders copy or the sales draft. (iii) Merchant is responsible for any failure by its agent to comply with all applicable rules and regulation of MasterCard and Visa, including, but not limited to, (i) The cardholder account number any violation resulting in a charge back. (ii) Merchants name (b) Merchant shall present all sales data relevant to a transaction to Acquirer within the lesser of three (3) bank business days or ve (5) calendar days after the date (iii) Merchants location code or city and state of the transaction, except that, (iv) The amount of the transaction (i) Merchant shall present no sales data until goods have been shipped or the services have been performed and Merchant has otherwise performed all or its (v) The transaction date principal obligations to the customer in connection with the transaction unless the cardholder agreed to a delayed delivery or goods and proper disclosures were(g) Transaction records must be produced for all transactions which originate at and are data captured using automated dispensing machines or limited amount made at the time of the transaction.terminals, except for transactions which originate at magnetic stripe reading telephones. Such transaction records must include at least the following information. (ii) When Merchant requests and receives authorization for delayed presentment and legibly prints on the sales slip the authorization number and the words (i) The cardholder account number "Delayed Presentment," Merchant must present the sales data within the period permitted for delayed presentment (not to exceed thirty (30) calendar days). (ii) Merchants name (iii) If Merchant is obligated by law to retain a sales slip or return it to a buyer upon timely cancellation, Merchant must present the sales data within ten (10) (iii) the magnetic stripe reading terminal location code or city and state bank business days after the date of the transaction; and (iv) the amount of the transaction (iv) When Merchant has multiple locations or o ces and accumulates transaction records at a central facility, Merchant must present the transaction records to (v) the transaction date Acquirer within (20) calendar days after the date of the transaction. Merchants with multiple locations must deliver the transaction records in such a manner that(h) Whenever the uncoded account number cannot be read from the magnetic stripe. Merchant shall follow normal authorization procedures and complete the Acquirer is able to identify the transactions originating at each location.approved transaction using a manual imprinter. (c) Merchant shall deliver all credit data to Acquirer within three (3) bank business days after the credit transaction date, except that if Merchant has multiple1.07 Multiple Transaction Records, Partial Consideration locations as described in subsection (b)(iv) above, Merchant must deliver the credit data to Acquirer within seven (7) business days after the transaction date.(a) Merchant must include on one transaction record the entire amount due for the transaction except in the following instances (d) Merchant shall not present to Acquirer, directly or indirectly, any transaction record that Merchant knows or should have known to be fraudulent or not (i) the transaction involves purchases made in separate departments of a multidepartment store authorized by the cardholder, that results from transaction outside Merchants normal course of business, that results from a transaction not involving Merchant, (ii) the transaction involves delayed or amended charges for a vehicle rental transaction in which that contains the account number of a Card account issued to Merchant, or that was not the result of a transaction between Merchant and a cardholder. (A) the cardholder consented to be liable for such charges (e) If the transmission of sales data or credit data from Merchant to Acquirer is in the form of magnetic tape or electronic data, Merchant shall preserve a copy of (B) such charges consist of ancillary or corrected charges such as taxes or fuel fees, and not charges for loss, theft, damage, or tra c violations, and the sales and credit slips as per section 3.03. (C) Merchant sends the cardholder a copy of the amended or add-on-sales drafts (Sales drafts for such delayed or amended charges may be deposited (f) Merchant is prohibited from re-depositing any transaction which has previously been charged back and subsequently returned to Merchant. This prohibitionwithout the cardholder signature provided that Merchant has cardholders signature on le, and the words "Signature on File" are entered onto the signature applies with or without the cardholders consent or the Merchants action. Merchant may, at its option, pursue payment from the customer in such event throughpanel of the sales draft). means other than a card transaction. (iii) the customer pays a portion of the transaction amount in cash, by check, with any card, or any combination of such payments at the time of the transaction 2.02 Acceptance and Discountand further provided that Merchant obtains authorization for that part of the transaction a ected with a card. (a) Subject to all terms and conditions contained herein, barring any event of insecurity as de ned in 2.03 below, and based on the proper execution and (iv) all or a portion of the goods or services are to be delivered or performed at a later date and the customer signs two separate sales slips, one of which presentment of electronic batches for settlement Acquirer will initiate payment to Merchant within three-(3) business days after the processing date of therepresents a deposit and the second of which represents payment of the balance, and the balance sales slip is completed only upon delivery of the goods or received batch for the total face amount of each Sales Draft less any Credits, Discounts, Fees, Reserve Deposits or adjustments. However, Acquirer cannotperformance of the services in which case Merchant agrees guarantee the timeliness with which any payment may be credited by Merchants Bank to Merchants account and such payments will be subject to Merchants (A) to note on the sales slips the word "deposit" or "balance" as appropriate and the words "Delayed Delivery" Bank’s funds availability policies. All payments, credits, and charges are subject to audit and nal checking by Acquirer, and prompt adjustments shall be made for (B) if the total amount of the two slips exceeds the applicable oor limit, to obtain prior authorization and note the authorization date and approval code on inaccuracies discovered.the sales slips, and 2.03 Insecurity (C) not to present the "balance" sales slip until all goods are delivered or all the services are performed, or (a) Notwithstanding Section 2.02 Acquirer may withhold payment to Merchant or prohibit Merchants withdrawal of funds then on deposit with Acquirer for any of (v) the cardholder is using the installment payment option o ered in accordance wit section 1.08 the following reasons;(b) Merchant agrees not to divide a single transaction between two or more transaction records to avoid obtaining an authorization (i) Acquirer is suspicious of any transaction records;(c) For sales processed at electronic P.O.S. terminals, multiple items individually billed to the same account will not be considered a violation of this Agreement if (ii) Merchants volume of sales exceeds a stipulated amount or amounts that are typically generated during a particular period;separate authorizations are obtained for each item. (iii) Merchants average ticket amount exceeds a stipulated amount; (iv) Merchant does not swipe Cards through electronic terminals;1.08 Telephone Order, Mail Orders, Preauthorized Orders and Installment Orders (v) Merchant fails to authorize transaction;(a) If a Card transaction is made by telephone order (TO), mail order (MO), or preauthorized order (PO), the sales slip may be completed without a customers (vi) Acquirer receives excessive retrieval request against Merchants account as prior activity.signature or a Card imprint, but Merchant shall (vii) Excessive charge backs are debited against Merchants account as prior activity; or (i) print legibly on the sales slip su cient information to identify the card issuer, Merchant and the cardholder including, Merchants name and address, the Card (view) If for any other reason Acquirer reasonably determines that withholding funds or preventing withdrawal of funds previously deposited with Acquirer isissuers name or trade style, ICA number and bank initials (if any), the account number, the expiration date and any e ective date on the Card the cardholders necessary to cover anticipated charges from Merchants Card activities.name, and any company name, and (b) In the event of the use of any provision in 2.03 (a) above it may be determined that a Pledged Reserve Account for Merchant must be established. This Account (ii) print legibly on the signature line of the sales slip the letter "TO", "MO" or "PO" (Recurring transaction for Visa transaction), as appropriate can consist of an initial contribution requirement, a diversion of a percentage or all of current and/or future transactions or any combination thereof as determined (iii) obtain authorization for every sale for MO and TO( transactions, authorization must be obtained no more than seven calendar days prior to the transaction by Acquirer. Funds held will remain on deposit with Acquirer for a period of two-(2) years or until Acquirer determines, in its sole and absolute discretion, that thedate. Merchant shall attempt to obtain the expiration date of the Card as part of the authorization inquiry. risk of charges to the Merchants account has past.(b) in any non-imprint transaction (and whenever an expired Card is presented regardless of whether imprinted), Merchant shall be deemed to warrant the (c) Pledged Reserve Accounts can be applied to any debt of merchant to Acquirer and/or EPS.customers true identity as an authorized user of the Card, whether or not authorization is obtained, unless Merchant obtains and notes legibly on the sales slipevidence of the customers true identity X By Initialling Here You Are Con rming Acceptance and Receipt of This Agreement and a Copy Thereof
  • 4. 2.04 Prohibited Payment 3.13 Payment Card Industry Data Storage Standard (PCI DSS)Merchant agrees that Acquirer has the sole right to receive payments on any accepted transaction record as long as; As a Merchant if you store Cardholder Data in any way, shape, or form you are required to maintain that information in a secure manner. The guidelines for Data(a) Acquirer has paid Merchant the amount represented by the transaction record less the discount and fees, and Storage can be found in detail at VISA.COM [type in PCI DSS in the search bar and follow the links to the information that applies to you], or contact the EPS Risk(b) Acquirer has not charged such transaction record back to Merchant unless speci cally authorized in writing by Acquirer, Merchant agrees not to make or Department at 800-863-5995. EPS will be happy to explain the process and responsibilities related to this important Integrated Card Solution requirement.attempt to make any collections on any transaction record Merchant agrees to hold in trust for Acquirer any payment Merchant receives or all or part of the 3.14 Generalamount of any accepted transaction record, and promptly to deliver the same in kind to Acquirer as soon as received, together with the cardholders name and (a) The paragraph headings and captions contained in this Agreement are for convenience only, and should not be deemed to de ne, limit or describe the scopeaccount number and any correspondence accompanying the payment. or intent of this Agreement to the extent that they con ict with the substance of this Agreement.2.05 Chargeback (b) This Agreement shall be binding upon and inure to the bene t of the parties hereto and their successors and assigns, provided, however, this Agreement may(a) Under any one or more of the following circumstances, Acquirer may charge back to Merchant any transaction record that Acquirer has accepted , and not be assigned by Merchant without the written consent of Acquirer. Any such assignment by Merchant without Acquirers prior written consent shall be null andMerchant shall repay Acquirer the amount represented by the transaction record plus any associated fees: void. (i) the transaction record or any material information on a sales slip (such as the account number, expiration date of the Card, Merchant description, transaction (c) Should any provision of this Agreement contravene any law, or valid regulation or rule of any regulatory agency or self-regulatory body having jurisdiction overamount, or date) is illegible, incomplete, or otherwise indiscernible, is not endorsed, or is not delivered to Acquirer within the required time limits; either party hereto, or should any provision of this Agreement otherwise be held invalid, or unenforceable by a court or other body of competent jurisdiction, then (ii) the transaction was one which received a negative account veri cation service response (or would have received a negative account veri cation service each such provision shall be automatically terminated and performance hereof by both parties waived, and all other provisions of this Agreement then in e ectresponse if Merchant had contacted the service on the transaction date) and Merchant did not reject the transaction or receive prior authorization for the shall nevertheless remain in full force and e ect.transaction, as applicable; (d) No failure by Acquirer to insist upon strict performance during continuance or default hereunder, shall constitute a waiver of any such term, obligation, right or (iii) the sales slip does not contain the required imprint of a Card that was valid, e ective, and unexpired on the transaction date. remedy, or a waiver of any such default by Acquirer. (iv) the transaction was one for which prior credit authorization was required and prior credit authorization was not obtained, or a valid authorization number is (e) This Agreement shall be governed and construed in accordance with the laws of the State of Colorado. Merchant agrees that the exclusive venue for any and allnot correctly and legibly included on the transaction record; proceedings relating to this Agreement shall be a court located in Colorado. (v) The transaction record is a duplicate of an item previously paid, or is one of two or more transaction records generated in a single transaction in violation of (f) Merchant will be liable for and indemnify Acquirer for any and all attorneys fees and other related costs and expenses paid or incurred by the Acquirer in thethis Agreement. enforcement hereof, or in collecting any amounts due from merchant to Acquirer hereunder or resulting from any breach by Merchant of any of the terms or (vi) the cardholder disputes the execution of the transaction record, the sale, delivery, quality, or performance of the goods or services purchased, or alleges conditions of this Agreement.that a credit adjustment was requested and reissued or that a credit adjustment was issued by Merchant but not posted to the cardholders account; (g) In the event of the occurrence of other disputes not covered or part of 3.13 (f ) above, the prevailing party will be entitled to receive reimbursement of all legal (vii) the price of the goods or services shown on the transaction record di ers from the amount shown on the copy of the sales slip or the receipt delivered to fees associated with the dispute.the customer at the time of the transaction; (h) Acquirer may amend this Agreement at any time without prior notice to Merchant. Such amendment shall take e ect at the time of noti cation to Merchant (viii) Acquirer reasonably determines that Merchant has violated any term, condition, covenant, warranty, or other provisions of this Agreement in connection and be incorporated herein as if part of the original Agreement.with the transaction record or the transaction to which it relates. (i) All notices or other communications required to be given by either party shall be in writing and shall be hand delivered or sent by United States certi ed mail, (ix) Acquirer reasonably determines that the transaction record is fraudulent or that the related transaction is not a bona de transaction in Merchants ordinary postage prepaid, and shall be deemed to be given when hand delivered or upon deposit in the mail as indicated. Notices shall be addressed to the parties at thecourse or business, or is subject to any claim of illegality, cancellation, rescission, avoidance, or o set for any address identi ed below, or such other address as may be speci ed by either party by notice to the other party.reason whatsoever, including without limitation negligence, fraud, or dishonesty on the part of Merchant or Merchants agents or employees; (j) Acquirer may appoint an agent(s) to do or take any actions that may be done or taken by Acquirer under this Agreement. (x) The transaction record arises from a mail or telephone order transaction which the cardholder disputes entering into or authorizing, or which involves an (k) This Agreement is intended by the parties as a nal expression of and a complete and exclusive statement of the terms of this Agreement, there being noaccount number that never existed or that never existed or that has expired and has not been renewed; conditions to the enforceability of this Agreement. This Agreement may not be supplemented or modi ed except in writing as provided for in this Agreement. (xi) Merchant fails to provide any sales slip or credit slip to Acquirer in accordance with Section 3.01 of this Agreement; NOTICES: EPS (xii) Any other Merchant transaction charged back to Acquirer for whatever reason pursuant to Visa or MasterCard rules and regulations. 6472 SOUTH QUEBEC STREET(b) In the event Merchant believes a chargeback to be improper, Merchant must notify Acquirer of this in writing within the (10) calendar days of the date of the ENGLEWOOD, CO 80111chargeback or forfeit its right to contest the chargeback.(c) Except in the case of chargeback’s that are based solely on the Merchants failure to obtain an authorization, Acquirer may chargeback a transaction in EPS 90 ARTICLES, TERMS AND CONDITIONSaccordance with this section even if an authorization was obtained in connection with the transaction. For the sake of this Agreement, Electronic Payment Systems, LLC ("EPS") d/b/a EPS 90, 6472 S. Quebec Street, Englewood, CO 80111 and Merchant listed, ifARTICLE III MISCELLANEOUS approved by EPS, agree to enter into this Agreement and to be bound by the contractual provisions contained herein in order to receive the substantial bene ts set forth herein and which EPS would not otherwise confer upon Merchant.3.01 Records NOW, THEREFORE, in consideration of the premises and mutual promises contained in this Agreement, the parties agree as follows:(a) Merchant shall for Visa, MasterCard, and Discover Network purposes preserve a copy of the actual paper sales slips and credit slips for at least six (6) months 1. Termafter the date Merchant presents the transaction data to Acquirer, and Merchant shall make and retain for at least three (3) years from such date legible micro lm If approved, this Agreement shall be e ective from the date hereof and shall remain in full force and e ect for a period of ONE (1) year as an initial term, unlesscopies of both sides of such actual paper transaction records. sooner terminated as set forth herein. Upon the completion of the initial term, unless Merchant furnishes written notice of non-renewal at least THIRTY (30) days(b) Merchant agrees to immediately notify Acquirer of any merchant location(s) added after the date of this Agreement, and agrees to the establishment of a prior to completion of the then existing term, this Agreement shall renew automatically for additional ONE (1) years terms in perpetuity unless canceled inseparate processing account for said location(s). accordance with the provisions contained in the Agreement. In any event of early termination3.02 Requests for Copies (a) all fees for the full term of the Agreement are immediately payable and Merchant hereby authorizes EPS 90 or its’ agent to collect said fees from any account(a) Within one (1) business day of receipt of any request by Acquirer, Merchant shall fax or mail to Acquirer either the actual paper transaction record, if requested owned by Merchant and/or guarantor(s) via Automated Clearing House (ACH) transactions,by Acquirer, or a legible copy thereof (in size comparable to the actual paper transaction records), and any other documentary evidence available to Merchant and (b) all prior guarantees shall be made null and void, and c) Merchant assigns all proceeds of pending conversion authorizations to EPS 90 to the extent they arereasonably requested by Acquirer to meet its obligations under law (including its obligations under the Fair Credit Billing Act) or otherwise to respond to required to satisfy any fees that may be due EPS 90. Once all fees due EPS 90 are satis ed any remaining conversion proceeds will be distributed to Merchantquestions concerning cardholder accounts. ninety-(90) days after the posting of the last delayed presentment.(b) For purposes or retrieval of records Merchant must retain sale slips and credit slips by reference number within date sequence. 2. Termination Upon Breach(c) If Merchant does not provide a requested copy of sales slip(s) to Acquirer within the time frame speci ed, in addition to other rights and remedies available to This Agreement may be terminated immediately by EPS 90 in the event of a breach of any representation, warranty, condition, provision, section or covenant inAcquirer under this Agreement; this Agreement. Merchant shall have the right to cure any breach that is susceptible of cure during the initial FIVE (5) days from the date of discovery and if the (i) Acquirer may charge Merchant a penalty fee, and breach is cured to the reasonable satisfaction of EPS 90, this Agreement shall not be terminated and shall continue in full force and e ect. In any event of early (ii) Acquirer may charge Merchant the transaction amount of the requested sales slip, termination all fees for the full term of the Agreement are immediately payable and Merchant hereby authorizes EPS 90 or its’ agent to collect said fees from any (iii) Acquirer may, at its option, charge Merchant the transaction amount of the requested sales slip at the time of the request. Such amount will be reimbursed account owned by Merchant and/or guarantor(s) via Automated Clearing House (ACH) transaction.to the Merchant upon delivery of a valid and correct sales slip. 3. EPS 90 - No Credit Check Easy Payment Plan Conversion - With Guarantee3.03 Disputes With Cardholder: Indemni cation EPS 90 will convert and/or commercially imprinted personal checks received by Merchant from customers through the EPS 90 – Online Software and purchase allAll disputes between Merchant and any cardholder relating to any Card transaction shall be settled between Merchant and such cardholder. Merchant shall approved commercially imprinted personal transactions presented for payment of goods and/or services germane to the Standard Industry Code (SIC Code) thatindemnify and hold Acquirer harmless from all claims, liabilities, losses, and expenditures (including reasonable attorneys fees and other costs of defence) relating bests describes your business that are converted which fail to clear subject to the following terms and conditions provided “% per check” is not waived:to or arising out of any such Card transaction and from Merchants failure to comply with any or its obligations under this Agreement. (a) The check instruments are made payable to Merchant.3.04 Excessive Chargeback’s and/or Retrievals (b) Merchant and Customer have fully completed and signed at the time of sale an “in-house nancing” form.Merchant agrees that in the event Acquirer is presented, during any monthly period, with chargeback’s and/or retrieval requests relating to the transactions of the (c) The Merchant has not accepted subsequent payment in any form for dishonored check instrument in full or part including but not limited to cash, check,Merchant processed by Acquirer in excess of one percent (1%) of interchange volume of such transactions, such chargeback and/or retrieval requests will service performed, trade, barter or return if goods dishonored check instrument was written for. In the event of received payment as described herein Merchantconclusively be deemed to be excessive under applicable Visa, MasterCard, and Discover Network regulations which shall allow Acquirer to take such action as shall notify EPS 90 immediately.may be authorized herein or by applicable Visa, MasterCard, or Discover Network regulations. (d) Merchant shall not accept two party, multi-party, signature irregular, EPS 90 declined, previously bank returned, stop, stop pay, temporary, stolen, for cash, and3.05 Terms, Termination and Combined Terminated Merchant File check instruments known at time of sale to be non-negotiable. Such acts+ may be considered non-conforming and subject to forfeiture of guarantee status.(a) The initial term of this Agreement shall be one (1) year from the date herein. Thereafter, the Agreement will automatically renew for additional one (1) year (e) The full daytime telephone number and drivers license or state issued ID number with expiration date (must be unexpired) being used as reference for theterms, unless merchant noti es acquirer of its intention not to renew the Agreement at least ninety (90) days prior to the end of the Agreement term then in e ect. writer must be clearly written on the FRONT of the check instrument.Merchants obligations under this Agreement remain in full force and e ect relative to all debt purchased under this Agreement. This Agreement may be (f) Merchant must warrant and attest that they have con rmed the identity of the check writer and the writer is the account holder, the writer is the namedterminated at any time by Acquirer upon written notice to the Merchant. Such notice shall be e ective when hand delivered or deposited in the mail or upon any individual on the face of the check instrument, all check instruments submitted and authorizations for the transaction were signed by the writer in person at thelater date speci ed in the notice. Acquirer may terminate this agreement without prior notice in the event Merchant is or becomes bankrupt or is unable to pay its time of sale, and the amounts of the check instruments constitute full payment for the goods and/or services purchased.debts as they become due, or if Acquirer reasonably determines that Merchant has violated any term, conditions, covenant, or warranty of this Agreement, or if (g) Unless otherwise noted Merchant account deposits are forwarded to the Federal Reserve for clearing to Merchants deposit account within 24 to 72 hours fromAcquirer determines in its sole discretion that Merchant has abused its privileges under this Agreement. date to present.(b) Upon the e ective date of any such termination, Merchants rights hereunder to make Card transactions, to deposit transaction records with Acquirer and to (h) Deposits made will be total check instrument amount minus fees due for the conversion service and prior chargebacks if any.use sales slip forms, credit slip forms, promotional material, and any other items provided by Acquirer hereunder shall cease, but Merchants obligations in (i) If a customer’s check instrument is charged back to EPS 90 for any reason Merchant will respond to retrieval request from EPS 90 for same in a timely manner. Inconnection with any transaction record accepted by Acquirer (whether before or after such termination), including without limitation Merchants chargeback addition, payment of funds for check instruments may be held back or reversed to cover chargebacks until guarantee status can be determined.obligations, shall survive such termination. (j) Merchant guarantees the availability of funds to cover chargebacks.(c) Merchant expressly acknowledges that a Combine Terminated Merchant File (CTMF) is maintained by MasterCard containing information on Merchants (k) In the event of a disputed transaction by any party, funds for same may be withheld until dispute is settled.terminated for one or more reasons speci ed in the MasterCard operating rules and regulations. Such reasons generally include, but are not limited to fraud, (l) Limits may be set for single check and daily deposit amounts. These limits may include additional time to deposit.counterfeit paper, unauthorized transactions, excessive chargeback’s, violations of Merchant Agreement or highly suspect activity Merchant acknowledges that (m) Merchant is required to cooperate with EPS 90 and follow instructions given by EPS 90 related to any veri cation or collection e orts. Failure to do so will resultAcquirer is required to report the Merchant business name and the names of its principles to the CTMF when Merchant is terminated due to one or more of the in forfeiture of any unsecured funds. This cooperation may entail the production of the original instrument.foregoing reasons. Merchant expressly agrees and consents to such reporting by Acquirer in the event of the termination of this Agreement due to one or more of (n) Merchant must warrant and attest that proper customer noti cation will be given prior to converting check instruments to debits.such its sole discretion in order to secure Merchants obligations under this Agreement. Merchant agrees to execute any documents or take any actions required in (o) Merchant shall keep and maintain all original copies of all check instruments submitted to program for a period of not less than ninety-(90) days from the dateorder to comply with and perfect the security interest under this paragraph. Acquirer and/or EPS may, at any time there is an obligation owing from Merchant to of presentment and shall deliver such check instrument to EPS 90 immediately upon request.Acquirer and/or EPS, set o any such amounts against any deposit balances or other money now or hereafter owed Merchant by Acquirer and/or EPS without (p) In the event of termination of this Agreement by either party funds due Merchant may be held and or debited from Merchant’s account to cover potentialnotice or demand of any kind. chargebacks.(d) This Agreement shall become e ective upon acceptance by Bank. Any party may terminate this Agreement at anytime with or without cause by providing (q) Merchant agrees to abide by and be bound to the rules and regulations of the “National Automated Clearing House Association” (NACHA), and any other entitywritten notice to the other parties. However, if Merchant terminates this Agreement, Bank and EPS shall have thirty (30) days from date of receipt of the notice to having authority to regulate or in any way control the use of conversion services.delete Merchants account during which time Merchant shall remain liable for all fees and charges, including any monthly minimum processing charge. Bank or (r) Any or all guaranteed check instruments may be charged back in the event any fraud or deception from or by Merchant or Merchants’ employees is discovered.EPS may terminate this Agreement immediately without prior notice if: If a previously guaranteed check instrument is later found not eligible for the guarantee program it may be charged back. (i) either party has reason to believe that fraudulent Card Transactions or other activity prohibited by this agreement is occurring at any Merchant location, (s) Merchant shall not have returns for any reason that represent FIVE-(5)% percent of total dollar volume for any period. In the event that Merchant exceeds the (ii) such action is taken to prevent loss to Bank, EPS, or Card issuers, FIVE-(5)% limit, no check instruments will be available for guarantee until Merchant’s aggregate return rate returns to below the stated and acknowledged limit. (iii) Merchant appears on any Integrated Card Solutions security reporting, or (iv) Banks Merchant Acceptance Criteria changes. All rights and obligations of the 4. EPS 90 - Single Check Conversion - With Guaranteeparties existing hereunder as of the e ective time of termination shall survive the termination hereof. EPS 90 will convert commercially imprinted personal checks received by Merchant from customers and purchase all approved commercially imprinted personal3.06 Limitation of Liability checks presented for payment of goods and/or services germane to the Standard Industry Code (SIC Code) that bests describes your business that are convertedAcquirers liability to Merchant with respect to any Card transaction shall not exceed the amount represented by the transaction less any applicable discount, and which fail to clear subject to the following terms and conditions provided “% per check” is not waived:Acquirer shall in no event be liable for any incidental or consequential damages whatsoever. Acquirer is not liable to Merchant for errors made by account number (a) All terms and conditions of 3 above and all subsections thereof apply to all transactions contemplated herein except Section 3. b. which does not apply.veri cation service or for Merchants failure to contact same. (b) Post dated checks do not qualify for the “Single Check Conversion Program.”3.07 Supplementary Documents; Fees 5. Payment To MerchantAll reference herein to this "Agreement" shall collectively included current Schedules, Amendments, Merchant Application, Change Notices, Addendum, Payment to Merchant for single check conversion program checks covered under this agreement are subject to ALL conditions contained herein and furthermoreAppendices and Attachments and associated reference materials, all or which are incorporated herein by reference and made a part of this Agreement as if fully those speci cally addressed in Section 4 and all subsections thereof above. Payment for No Credit Check EZ Payment Plan converted check instrument conversionset forth herein. Merchant agrees to pay the fees and charges identi ed in this Merchant Application or in any other schedule of fees and charges provided to program checks covered under this agreement are subject to ALL conditions contained herein and furthermore those speci cally addressed in Section 3 and allMerchant which may be amended from time to time as provided in Section 3.16. subsections thereof above. In the event a check instrument fails and becomes subject to the Guarantee Program, payment of the Guaranteed funds shall be made(a) An Annual Fee of $85.00 will be charged to all Merchant Accounts based on the number of Active Terminals per Merchant in December of each Calendar Year on or about the 10th or 25th (Guarantee Payment Dates) of each month for the activity prior to the last Guarantee Payment Date.regardless of enrolment time. This Fee is not refundable for any reason and cannot be pro-rated or abated in any way. 6. Miscellaneous3.08 Compliance with Law (a) This is the entire agreement between Merchant and EPS 90, with respect to the subject matter hereof, and supersedes any prior agreement, discussions orMerchant shall comply with all laws applicable to Merchant, Merchants business and any Card transaction, including but not limited to and without limitation all correspondence, oral or written, between Merchant and EPS 90. The check program guidelines attached hereto are incorporated herein by reference as if set out instate and federal consumer credit and consumer protection statutes and regulations and Visa, MasterCard and Discover Network regulations. full herein.3.09 Modi cation (b) This Agreement and all questions arising in connection herewith shall be governed by and construed in accordance with the laws of the State of Colorado, andThis Agreement is subject to such modi cations, changes, and additions as may be required, or deemed by Acquirer to be required, by reason of any state or all suits hereunder or in respect hereto by either party shall be instituted in the Colorado courts or in the United States District Court for the District of Coloradofederal statute, judicial decision, MasterCard, Visa, or Discover Network rule or regulation, or the regulation or ruling of any federal agency having jurisdiction over and in no other venue or jurisdiction. Merchant HEREBY SUBMITS TO THE JURISDICTION AND VENUE OF THE COURTS OF THE STATE OF COLORADO OR IN THEAcquirer or Merchant. UNITED STATES DISTRICT COURT FOR THE DISTRICT OF COLORADO, AND HEREBY CONSENTS TO SERVICE OF PROCESS AT MERCHANT’S ADDRESS SET FORTH3.10 Independent Sales Organization/Member Service Provider ABOVE.Merchant acknowledges that: (c) Representations made by the Independent Contractor or their employees, representative or any other persons associated with them that are not expressly (i) Acquirer may use an independent Sales Organization (ISO) or Member Service Provider (MSP) operating under applicable Visa, MasterCard, Discover Network contained in this Agreement ARE NOT VALID and do not apply. EPS 90 makes no representations outside of this Agreement. If you rely on representations made byrules and regulations who is an independent contractor and not an agent of Acquirer. Contractor not contained in this Agreement you are doing so of your own free will and at your own risk and shall not place any claim of any sort on EPS 90 for such (ii) No ISO or MSP has authority to execute this Agreement on Acquirers behalf or to alter the terms hereof without Acquirers prior written approval; and reliance. (iii) Representations made by Independent Sales Organizations, Member Service Providers, contractors or their employees, coworkers, assigns, contractors or (d) The section headings contained in this Agreement are for convenient reference only, and shall not in any way a ect the meaning or interpretation of thisany other persons associated with them that are not expressly contained in this Agreement ARE NOT VALID and do not apply. Acquirer makes no representations Agreement.outside of this Agreement. If you rely on representations that are not contained in this Agreement then you are doing so of your own free will and WILL NOT in any (e) Nothing contained in this Agreement shall be construed to constitute a joint venture or partnership between or among any persons or entities referred toway have recourse, right, claim or claims Whatsoever against EPS, Acquirer, Integrated Card Solution, or any of their a liates or entities. herein.3.11 Security Interest, Set-O (f) If any provision of this Agreement is at any time adjudged invalid or unenforceable to any extent by any court of competent jurisdiction, such provision shall beTo secure all obligations of Merchant to Acquirer and/or EPS arising from this Agreement and supporting Agreements to this application, Merchant hereby grants deemed modi ed to the extent necessary to render it valid and enforceable and such invalidity or unenforceability shall not a ect any other provision of thisAcquirer and/or EPS a st lien security interest on all deposits regardless of source, to Merchants accounts, whether known or unknown at the time of application, Agreement.and all proceeds of said deposits. Acquirers and EPSs rights under said security interest may be exercised by Acquirer and EPS without notice or demand of any (g) MERCHANT ACKNOWLEDGES THAT THIS IS A LEGAL DOCUMENT AFFECTING MERCHANT’S RIGHTS AND OBLIGATIONS. MERCHANT FURTHER ACKNOWLEDGESkind by making an immediate withdrawal from or freezing said account upon Acquirers and/or EPSs reasonable determination that a breach of any obligation of THAT THEY HAVE BEEN ENCOURAGED TO HAVE THIS AGREEMENT REVIEWED BY COUNSEL OF MERCHANT’S CHOOSING PRIOR TO ENTERING INTO THIS AGREEMENTMerchant under this Agreement or any other supporting Agreement, has occurred or for any reason speci ed in section 2.03. Exercising of Acquirers and EPSs AND THAT MERCHANT HAS CONSULTED WITH SUCH COUNSEL TO THE EXTENT THEY DESIRES TO DO SO. MERCHANT ACKNOWLEDGES THAT THEY ARE ENTERINGrights pursuant to this security interest shall be in addition to any other rights of Acquirer and/or EPS under this Agreement. Acquirer and/or EPS shall also have INTO A LEGAL AND BINDING AGREEMENT AND ARE FULLY AWARE OF ALL RAMIFICATIONS THEREIN.the right to require Merchant to furnish such other and di erent security as Acquirer and/or EPS shall deem appropriate in its sole discretion in order to secure (h) By a xing their signature(s) hereto on behalf of the Merchant, the undersigned individual(s) represent and a rm that they are binding themselves personallyMerchants obligations under this Agreement. Merchant agrees to execute any documents or take any actions required in order to comply with and perfect the and further that Merchant has the power and authority to enter into this Agreement and the execution and delivery of this Agreement and the performance ofsecurity interest under this paragraph. Acquirer and/or EPS may, at any time there is an obligation owing from Merchant to Acquirer and/or EPS, set o any such Merchant’s obligations hereunder have been duly authorized by all necessary corporate or company action.amounts against any deposit balances or other money or hereafter owed Merchant by Acquirer and/or EPS without notice or demand of any kind. 7. Credit Report Authorization3.12 Anti Money-Laundering Policy Merchant authorizes EPS 90 to obtain an investigative and/or consumer credit report, personal and/or commercial in nature, in connection with this Agreement.In compliance with the “Providing Appropriate Tools Required to Intercept and Obstruct Terrorism” Act (USA PATRIOT Act) ("Act"), Pub. Law 107-56(2001), Electronic 8. Electronic Debit/Credit AuthorizationPayment Systems ("EPS") has adopted an Anti-Money Laundering (AML) compliance policy ("Policy"). Merchant hereby authorizes EPS 90, in accordance with this Agreement, to initiate debit/credit entries to Merchant’s accounts. This authority is to remain in full It is the policy of EPS to prohibit and actively pursue the prevention of money laundering and any activity that facilitates money laundering or the funding of force and e ect untilterrorist or criminal activities. EPS is committed to AML compliance in accordance with applicable law and requires its o cers, employees and appointed (a) all obligations of Merchant to EPS 90 that have arisen under this Agreement have been paid in full andcontractors, agents, and vendors to adhere to these standards in preventing the use of its products and services for money laundering purposes. (b) EPS 90 has received written noti cation from Merchant of its termination, in such a manner as to a ord EPS 90 reasonable opportunity to act on it. This For the purposes of the Policy, money laundering is generally de ned as engaging in acts designed to conceal or disguise the true origins of criminally derived authorization extends, but is not limited to, entries to Merchant’s account for fees, applied percentages, monthly minimums, chargebacks, retrievals, check andproceeds so that the unlawful proceeds appear to have been derived from legitimate origins or constitute legitimate assets. check instrument rejects, and any other incidents for which funds may become due under this Agreement. Terrorist nancing may not involve the proceeds of criminal conduct, but rather an attempt to conceal the origin or intended use of the funds, which will laterbe used for criminal purposes. NOTICES: EPS 90 By accepting this Agreement Merchant hereby pledges and promises not to participate in any activity that may be construed as a violation of the above noted 6472 SOUTH QUEBEC STREETAct and this Anti Money-Laundering Policy and shall furthermore cooperate, comply, and assist in any e orts to assure compliance by Acquirer, EPS, Integrated ENGLEWOOD, CO 80111Card Solution, or Government Agency. VER V 20090514-01 X By Initialling Here You Are Con rming Acceptance and Receipt of This Agreement and a Copy Thereof
  • 5. LADCO Leasing 7300 Chapman Highway, Knoxville, Lease Number Lease Start Date Tennessee 37920 1-800-678-8666 NON-CANCELLABLE EQUIPMENT FINANCE LEASE (Commercial) ABOUT YOUR BUSINESSLESSEE CORPORATE BUSINESS NAME DBA NAME TAX ID NO.BILLING ADDRESS CITY STATE ZIP CODE TELEPHONE ( )BUSINESS ADDRESS (IF DIFFERENT FROM BILLING) CITY STATE ZIP CODE TELEPHONE ( )TYPE OF BUSINESS Corporation Partnership Sole Proprietorship LLC Other____________ YEARS IN BUSINESS______________ EQUIPMENT SUPPLIERSUPPLIER NAME TELEPHONEBILLING ADDRESS CITY STATE ZIP CODE EQUIPMENT & PAYMENT INFORMATIONDESCRIPTION (MANUFACTURER, MODEL) QUANTITY________________________________________________ _________ LEASE TERM _________ MONTHS________________________________________________ ________ MONTHLY PAYMENT $_______________ (PLUS TAXES, IF APPLICABLE)________________________________________________ ________ ABOUT YOUR BANKBANK NAME BRANCH / ABA NO. BUSINESS CHECKING ACCOUNT NO.I (Lessee), in the capacity set forth below, hereby authorize LADCO Leasing, a division of Elavon, Inc., or its designee, successor or assign (hereinafter“Lessor”) to withdraw any amounts, including any and all taxes now due or imposed, owed by me in conjunction with the above referenced transaction,by initiating debit entries to my account at the financial institution (hereinafter “Bank”) indicated above, or as such other Bank as the Lessee may fromtime to time use. In the event of default of my obligation hereunder, I authorize debit of my account for the full amount due under this Lease Agreement.Lessee agrees to contest transactions that might be invalid within ninety days of the transaction date, or the transaction will be deemed valid. A rentalpayment (whether paid by debit or other means) that is not honored by my Bank for any reason will be subject to a returned item service fee imposed byLessor, the amount of which may be debited from my account. Should it be necessary to switch to statement billing, Lessor is authorized to add a $5.00per month service charge to my monthly payment amount as reimbursement for the added service and processing expenses. In the event that LESSORwithdraws funds erroneously from my account, I authorize Lessor to credit my account for an amount not to exceed the original amount of the debit.This authorization is to remain in full force and effect until Lessor and Bank have received written notice from me of its termination in such time and insuch manner as to afford Lessor and Bank a reasonable opportunity to act. I REPRESENT AND WARRANT ON BEHALF OF LESSEE THAT THIS CHECKINGACCOUNT HAS BEEN ESTABLISHED AS A BUSINESS-PURPOSE CHECKING ACCOUNT. LEASE ACCEPTANCE THIS IS A NON-CANCELLABLE LEASE FOR THE FULL TERM INDICATED HEREIN.The undersigned agrees to all terms and conditions contained in this Equipment Finance Lease Agreement. Lessee acknowledges receipt of a copy ofthis four page agreement with all terms and conditions filled in. Lessee acknowledges acceptance and receipt of the Equipment. Lessee certifies that theEquipment shall be used for business purposes, and affirms that he/she is a duly authorized corporate officer, partner or proprietor of the within namedLessee.Lessee (Authorized Signer) Title Print Name DateX PERSONAL GUARANTYThe undersigned unconditionally guarantees performance of the Lease by Lessee and payment of all sums due hereunder in the event of default of theterms of this Lease Agreement, hereby waiving any modification, amendment or extension and notice thereof and waiving any right the undersigned mayhave by statute (including without limitation, Section 10-7-24 of the Official Code of Georgia, Annotated) or otherwise, to require Lessor to institute suitagainst Lessee after notice or demand from the undersigned or to seek recourse first against Lessee, or to realize upon any security for the obligationsguarantied hereby, as a condition to enforcing the undersigned’s liability hereunder. The undersigned agrees to pay all attorneys’ fees and otherexpenses incurred by Lessor by reason of default by the Lessee. This is a continuing guaranty and shall not be discharged or affected by death of theundersigned, and shall bind the heirs, administrators, representatives, successors and assigns. The undersigned hereby directs any consumer reportingagency to furnish a consumer credit report that relates personally to the undersigned upon the request of Lessor, its designee, successor or assign; and,agrees that the parties involved are in compliance with the Fair Credit Reporting Act.Guarantor’s Signature Print Name DateX , an individualHOME ADDRESS CITY, ST, ZIP CODE HOME TELEPHONE SOCIAL SECURITY NUMBER (ACCEPTANCE BY LADCO LEASING DATEGeneral Use1-Rev 1/10 Page 1 of 4
  • 6. EQUIPMENT FINANCE LEASE TERMS1. NON-CANCELLABLE LEASE. THIS LEASE CANNOT BE Commencement Date"), and shall continue until the obligations of theCANCELLED BY LESSEE DURING THE TERM HEREOF. Lessor, Lessee under the Lease shall have been fully performed. Theits successors and assigns, does hereby lease to Lessee and Lessee installments of rent shall be payable monthly in advance as statedhereby rents from Lessor the equipment (“Equipment”) and/or above or on an schedule, the first such payment being due on thesoftware and related license agreement(s) (collectively, the Commencement Date, or such later date as Lessor designates in“Software”) described above (hereinafter with all replacement parts, writing, and subsequent payments shall be due on the same day ofrepairs, additions and accessories included therein and/or affixed each successive month thereafter until the balance of the rent andthereto, referred to as the “Equipment”), on terms and conditions set any additional rent or expenses chargeable to Lessee under thisforth herein and on the reverse side of this form for the term indicated Lease shall have been paid in full. All payments of rent shall be madeabove. to Lessor at address set forth herein or such other address as Lessor may designate in writing. Lessees obligation to pay such rentals shall2. NO WARRANTIES BY LESSOR. Lessee represents that Lessee be absolute and unconditional and is not subject to any abatement,has selected the Equipment leased hereunder and Lessee set-off, defense of counterclaim for any reason whatsoever. Lesseeacknowledges Lessor has made and makes no representations or hereby authorizes Lessor to insert into this Lease Agreement thewarranties of any kind or nature, directly or indirectly, expressed or serial numbers and other identification data of the Equipment whenimplied, as to any matter whatsoever, including the suitability of the determined by Lessor and dates or other omitted factual matters andEquipment, its durability, its condition, and/or its quality and, as to correct any typographical or spelling errors. If a security deposit isbetween Lessee and Lessor, or Lessor’s assignee. Lessee leases indicated above, the same shall be held by Lessor to secure thethe Equipment “As-Is”. Lessor also disclaims any warranty of faithful performance of the terms of the Lease and returned or appliedmerchantability or fitness for use or purpose whether arising by in accordance with Paragraph 16(d) hereof.operation of law or otherwise. Lessor and Lessor’s assignee shall notbe liable to Lessee or others for any loss, damage or expense of any 6. ASSIGNMENT. (a) LESSOR MAY ASSIGN OR TRANSFER THISkind or nature caused directly or indirectly by any Equipment however LEASE OR LESSORS INTEREST IN THE EQUIPMENT WITHOUTarising, or the use or maintenance thereof or the failure of operation NOTICE TO LESSEE. Any assignee of Lessor shall have all of thethereof, or the repairs, service or adjustment thereto. No rights, but none of the obligations, of Lessor under this Lease andrepresentation or warranty as to the Equipment or any other matter by Lessee agrees that it will not assert against any assignee of Lessorthe Equipment Supplier named above (the “Vendor”) or others shall any defense, counterclaim or offset that Lessee may have againstbe binding on the Lessor nor shall the breach of such relieve Lessee Lessor. Lessee acknowledges that any assignment or transfer byof, or in any way affect, any of Lessee’s obligations to Lessor herein. Lessor shall not materially change Lessees duties or obligationsIf the Equipment is not satisfactory for any reason, Lessee shall make under this Lease nor materially increase the burdens or risks imposedany claim on account thereof solely against the Vendor and Lessee on Lessee. Lessee agrees that Lessor may assign or transfer thisshall nevertheless pay Lessor all rent payable under this Lease. Lease or Lessors interest in the Equipment even if said assignmentLessor agrees to assign to Lessee, solely for the purpose of making or transfer could be deemed to materially affect the interest of Lessee.and prosecuting any such claim, any rights it may have against the (b) LESSEE SHALL NOT ASSIGN OR IN ANY WAY DISPOSE OFVendor for breach of warranty or representation respecting the ALL OR ANY PART OF ITS RIGHTS OR OBLIGATIONS UNDEREquipment. THIS LEASE OR ENTER INTO ANY SUBLEASE OF ALL OR ANY PART OF THE EQUIPMENT WITHOUT THE PRIOR WRITTENRegardless of cause, Lessee will not assert any claim whatsoever CONSENT OF LESSOR. (c) Lessee shall not create, incur, assumeagainst Lessor for loss of anticipatory profits or any other indirect, or suffer to exist any mortgage, lien, pledge or other encumbrance orspecial, or consequential damages. Lessor makes no warranty as to attachment of any kind whatsoever upon, affecting or with respect tothe treatment of this Lease for accounting or tax purposes. the Equipment or this Lease or any of Lessors interests thereunder.NOTWITHSTANDING ANY FEES WHICH MAY BE PAID BYLESSOR TO VENDOR OR ANY AGENT OF VENDOR, LESSEE 7. TITLE, QUIET ENJOYMENT. Lessor shall at all times retain titleUNDERSTANDS AND AGREES THAT NEITHER VENDOR NOR to the Equipment. All documents of title and evidence of delivery shallANY AGENT OF VENDOR IS AN AGENT OF LESSOR OR IS be delivered to Lessor. Lessee hereby authorizes Lessor, at LesseesAUTHORIZED TO WAIVE OR ALTER ANY TERM OR CONDITION expense, to cause this Lease or any statement or other instrument inOF THIS LEASE. respect to this Lease showing the interest of Lessor in the Equipment including Uniform Commercial Code Financing Statements, to be filed3. FINANCE LEASE. The parties agree that this lease is a "Finance or recorded and/or refiled and rerecorded, and grants Lessor the rightLease" as defined by Section 11-2A-103(g) of the Georgia Uniform to execute Lessee’s name thereto. Lessee agrees to execute andCommercial Code. (GA UCC) Lessee acknowledges either (a) that deliver any statement or instrument requested by Lessor for suchLessee has reviewed and approved any written Supply Contract as purpose, and agrees to pay or reimburse Lessor for any filing,defined by GA UCC Section 11-2A-103(y) covering the Equipment recording or stamp fees or taxes arising from the filing or recording ofpurchased from the "Supplier" as defined by GA UCC Section 11-2A- any such instrument or statement. Lessee shall at its expense,103(x) thereof for lease to Lessee or (b) that Lessor has informed or protect and defend Lessors title against all persons claiming againstadvised Lessee, in writing, either previously or by this Lease of the or through Lessee, at all times keep the Equipment free from legalfollowing: (2) the identity of the Supplier; (2) that the Lessee may have process or encumbrance whatsoever and, shall give Lessorrights under the Supply Contract; and (3) that the Lessee may contact immediate notice thereof and shall indemnify Lessor from any lossthe Supplier for a description of any such rights Lessee may have caused thereby. Lessee agrees to procure for Lessor, such estoppelunder the Supply Contract. certificates, landlords or mortgagees waiver or other similar4. ORDERING EQUIPMENT; LESSORS RIGHT TO TERMINATE. documents as Lessor may reasonably request. Provided Lessee isLessee requests Lessor to purchase the Equipment from Vendor and not in default hereunder, Lessee shall quietly use and enjoy thearrange for delivery to Lessee at Lessees expense. If within forty-five Equipment subject to the terms hereof.(45) days from the date Lessor orders the Equipment, the same has 8. CARE, USE AND LOCATION. Lessee shall maintain thenot been delivered, installed and accepted by Lessee in form Equipment in good operating condition, repair and appearance, andsatisfactory to Lessor, Lessor may on ten (10) days written notice to protect the same from deterioration other than normal wear and tear;Lessee terminate the Lease and its obligations to Lessee. shall use the Equipment in the regular course of its business, within5. TERM AND RENT. The sum of all periodic installments of rent its normal operating capacity, without abuse, and shall comply with allindicated herein or on any attached schedule shall constitute the laws, ordinances, regulations, requirements and rules with respect toaggregate rent reserved under this Lease. The Lease term shall the use, maintenance and operation of the Equipment; shall use thecommence as of the date that the Lease is accepted by Lessor, ("the Equipment solely for business purposes; shall not make anyLADCO General Use1 Ver 2/10 Page 2 of 4 Initials_________ Date_________
  • 7. EQUIPMENT FINANCE LEASE TERMSmodification, alteration or addition to the Equipment, without the person. In the event of loss, damage or destruction of any item ofwritten consent of Lessor, which shall not be unreasonably withheld; Equipment, Lessee at its expense (except to the extent of anyshall not at any time so affix the Equipment to realty as to change its proceeds of insurance provided by Lessee which shall have beennature to real equipment or to a fixture regardless of how attached or received by Lessor as a result of such loss, damage or destruction),installed; shall keep the Equipment at the location shown herein, and and at Lessor’s option, shall either (a) repair such item, returning it toshall not remove the Equipment without written consent of Lessor, its previous condition, unless damaged beyond repair; or (b) paywhich shall not be unreasonably withheld. Lessor all accrued and unpaid rental payments and late charges, plus an amount (the “Loss Amount”) equal to (i) the value of all rental9. NET LEASE; TAXES. Lessee intends the rental payments payments to become due during the remaining term of this lease, plushereunder to be net to Lessor, and Lessee agrees to pay all sales, (ii) the amount of any purchase option or obligation with respect to theuse, excise, personal equipment, stamp, documentary and ad Equipment or, if there is no such option or obligation, the fair marketvalorem taxes, license and registration fees, assessment, fines, value of the Equipment, as estimated by Lessor in its sole reasonablepenalties and similar charges imposed on the ownership, possession discretion; or (c) replace such item with a like item acceptable toor use of the Equipment during the term of this Lease; shall pay all Lessor, in good condition and of equivalent value, which shall becometaxes (except Lessors Federal or State net income taxes) imposed on equipment of Lessor, included within the term “Equipment” as usedLessor or Lessee with respect to the rental payments hereunder or herein, and leased from Lessor herewith for the balance of the fullthe ownership of the Equipment; and, shall reimburse Lessor upon term of this Lease.demand for any taxes paid by or advanced by Lessor. Lessee agreesthat the reimbursement of equipment tax calculation is based on an 13. LOSS OR DESTRUCTION WAIVER. Lessor may waiveaverage tax rate. Lessee agrees to pay Lessor an annual fee in an Lessees responsibility for loss or destruction of the Equipment and foramount not to exceed $50.00 for the administration, billing and keeping the Equipment fully insured during the lease term. For suchtracking of said taxes and charges. Unless otherwise agreed to in waiver, Lessee shall pay Lessor the monthly amount shown in thewriting, Lessee shall file personal equipment tax returns with respect Schedule of Payments section titled "Loss & Destruction Waiver"to the Equipment. (unless the term "Included" is shown). Should Lessee fail to provide proof of insurance, Lessor may invoke the Loss or Destruction Waiver10. INDEMNITY. Lessee shall and does hereby agree to indemnify and charge a monthly fee at current rates even if no amount is shownand save Lessor, its agents, servants, successors, and assigns in the aforementioned section of the Schedule of Payments. In theharmless from any and all liability, damage or loss, including event of loss or destruction of the Equipment, Lessor shall provide forreasonable attorneys fees, arising out of the ownership, selection, its replacement with Equipment of comparable value at that timepossession, leasing, operation, control, use, condition (including but provided (i) Lessee took reasonable care in preventing the loss ornot limited to latent and other defects, whether or not discoverable by destruction of the Equipment and (ii) Lessee has paid in a timelyLessee), maintenance, delivery and return of the Equipment. The manner the required monthly amount for the Loss or Destructionindemnities and obligations herein provided shall continue in full force Waiver. Lessee shall cooperate with Lessor in making any claim withand effect notwithstanding the termination of the Lease. respect to the Equipment.11. INSURANCE. . During the term of this Lease, Lessee agrees to 14. EVENT OF DEFAULT. If any one of the following events (eachmaintain, at Lessee’s expense, “Special Form” property insurance an "Event of Default") shall occur, then to the extent permitted byprotecting the Equipment for its replacement value, naming Lessor as applicable law, Lessor shall have the right to exercise any one ora loss payee on a “Lender’s Loss Payable” endorsement; public more remedies set forth in Paragraph 15 below: (a) Lessee fails toliability insurance, in amounts acceptable to Lessor, naming Lessor as pay any rental or any other payment hereunder when due; or (b)an additional insured (together "Required Insurance”). Lessee must Lessee fails to pay, when due, any indebtedness of Lessee to Lessorprovide Lessor satisfactory written evidence of Required Insurance arising independently of this Lease, and such default shall continue for five (5) days; or (c) Lessee fails to perform any of the terms,within thirty (30) days of the commencement date of this lease or any covenants, or conditions of this Lease, other than as provided above,subsequent written request. If Lessee does not do so, Lessor may after ten (10) days written notice; or (d) Lessee becomes insolvent orobtain insurance from an insurer of Lessor’s choosing in such forms makes an assignment for the benefit of creditors; or (e) a receiver,and amounts as Lessor deems reasonable to protect Lessor’s trustee, conservator, or liquidator of Lessee, of all or a substantial partinterests (“Lease Insurance”). Lease Insurance covers the Equipment of its assets, is appointed with or without the application or consent ofand the Lessor; it does not name the Lessee as an insured and may Lessee; or (f) a petition is filed by or against Lessee under the Unitednot cover all of the Lessee’s interest in the Equipment. Lessee agrees States Bankruptcy Code or any amendment thereto, or under anyto pay Lessor periodic charges for Lease Insurance (“Insurance other insolvency law(s), providing for relief of debtors.Charges”) that include: a premium that may be higher than if the 15. REMEDIES. If an event of default shall occur as described inLessee maintained the Required Insurance separately; a finance sub-paragraph (a) through (f) in Paragraph 14 hereinabove, Lessorcharge of up to 1.5% per month on any premium advances made by may, at its option, at any time (a) declare immediately due andthe Lessor or Lessor’s agents; and billing and processing fees; each payable and recover from Lessee, as liquidated damages for the lossof which may generate a profit to Lessor and Lessor’s agents. Unless of a bargain and not as a penalty, an amount equal to all accrued andLessee provides satisfactory evidence of Required Insurance by the unpaid rental payments and late charges, taxes, and other fees, plusInsurance Charge due date, Lessor will pay such Insurance Charge the Loss Amount as set forth in Paragraph 12 hereinabove; (b)by debiting Lessee’s account under the withdrawal provision of this automatically charge any or all of my bank accounts for all moneylease. Lessor shall discontinue billing Insurance Charges upon receipt amounts owed; (c) to the extent permitted by applicable law, withoutof satisfactory evidence of Required Insurance. Lessee agrees to demand or legal process, enter into the premises where thearbitrate any dispute with Lessor or Lessor’s agents regarding Lease Equipment may be found and take possession of and remove theInsurance or Insurance Charges under the rules of the American Equipment, without liability for such retaking; (d) Lessor may hold, sellArbitration Association in Atlanta, Georgia; provided however, such or otherwise dispose of any such Equipment at a private or public sale; or (e) any other remedies available under applicable law. In theagreement does not authorize class arbitration. event Lessor takes possession of the Equipment, Lessor shall give12. LOSS OR DESTRUCTION OF EQUIPMENT. Lessee shall bear Lessee credit for any sums received by Lessor from the sale or rentalthe entire risk and be responsible for loss, theft, damage or of the Equipment after deduction of the expenses of sale or rental anddestruction of the Equipment from any cause whatsoever after taking Lessee shall remain liable to Lessor for any deficiency.possession of the Equipment. Lessee shall notify Lessor immediately Notwithstanding the foregoing, to the extent Software isif the Equipment is lost, destroyed, stolen or taken by any other nontransferable or its transfer restricted, Lessee agrees that LessorLADCO General Use1 Ver 2/10 Page 3 of 4 Initials_________ Date_________
  • 8. EQUIPMENT FINANCE LEASE TERMSand/or Licensor of the Software shall have no duty to remarket such when due, Lessee agrees to pay Lessor, in addition to the payment, aSoftware or otherwise mitigate any damages relating to such late charge of 15% of the amount past due (but at least $7.50) forSoftware. Lessee shall also be liable for and shall pay to Lessor (a) all each late payment. Each month the past due payment remainsexpenses incurred by Lessor in connection with the enforcement of unpaid, an additional late fee in the amount defined will be assessed.any of Lessor’s remedies including all collection expenses, that Payments are applied to late fees and service charges first and thenincludes, but is not limited to, charges for collection letters and to Lease obligation. Amounts shall be payable in addition to allcollection calls, charges of collection agencies, sheriffs, etc.; and all amounts payable by Lessee to Lessor as a result of exercise of any ofexpenses of repossessing, storing, shipping, repairing and selling the the remedies herein provided. If Lessee requests any services notEquipment; and (b) reasonable attorney’s fees and court costs. provided for herein, Lessee agrees to pay an applicable fee forLessor and Lessee acknowledge the difficulty in establishing a value delivery of such services. Lessee shall inform Lessor of any change infor the unexpired lease term and, owing to such difficulty, agree that Lessees name, address, billing address, telephone numbers, locationthe provisions of this paragraph represent an agreed measure of of the Equipment, or the bank checking account used for ACH debit.damages and are not to be deemed a forfeiture or penalty. All In the event Lessee fails to comply with any provision of this Lease,remedies of Lessor hereunder are cumulative, are in addition to any Lessor shall have the right, but not be obligated, to affect suchother remedies provided for by law, and may, to the extent permitted compliance on behalf of Lessee upon ten (10) days prior writtenby law, be exercised concurrently or separately. The exercise of any notice to Lessee. In such event, all monies expended by, and allone remedy shall not be deemed to be an election of such remedy or expenses of Lessor in effecting such compliance, shall be deemed toto preclude the exercise of any other remedy. No failure on the part of be additional rental, and shall be paid by Lessee at the time of thethe Lessor to exercise and no delay in exercising any right to remedy next monthly payment of rent. All notices under this Lease shall beshall operate as a waiver thereof or modify the terms of the Lease. sufficient if given personally or mailed postage prepaid to the party intended at the respective address set forth herein, or at such other16. END OF LEASE TERM. (a) UPON EXPIRATION OF THE address as said party may provide in writing from time to time. ThisLEASE TERM, LESSEE SHALL HAVE THE OPTION TO Lease inures to the benefit of and is binding upon the personalPURCHASE EQUIPMENT FOR ITS FAIR MARKET VALUE, SAID representatives, successors and assigns of the parties hereto. Time isVALUE TO BE NOT LESS THAN 20% OF THE AGGREGATE of the essence of this Lease. Lessor and Lessee intend this Lease toLEASE PAYMENTS ON 12 MONTH LEASES, 15% OF be a valid and subsisting legal instrument, and agree that no provisionAGGREGATE LEASE PAYMENTS ON 24 MONTH LEASES, 12% of this Lease that may be deemed unenforceable shall in any wayOF THE AGGREGATE PAYMENTS ON 36 MONTH LEASES, OR invalidate any other provision or provisions of this Lease, all of which10% OF THE AGGREGATE LEASE PAYMENTS ON 48 MONTH OR shall remain in full force and effect. This Lease shall be binding when60 MONTH LEASES. THE EXERCISE OF THIS OPTION MUST BE accepted in writing by Lessor and shall be governed by the laws ofCOMMUNICATED TO LESSOR IN WRITING AT LEAST THIRTY the State of Georgia, provided however, in the event this Lease or any(30) DAYS PRIOR TO THE EXPIRATION OF THE LEASE TERM. provision hereof is not enforceable under the laws of the State of(b) IN THE EVENT LESSEE DOES NOT ELECT TO PURCHASE Georgia then the laws of the state where the Equipment is locatedTHE EQUIPMENT, THEN UPON EXPIRATION OR EARLIER shall govern. Lessee consents and submits to the jurisdiction of theTERMINATION OF THIS LEASE, LESSEE SHALL RETURN THE federal and state courts located in the State of Georgia and withinEQUIPMENT TO LESSOR IN GOOD OPERATING CONDITION Fulton County (the “Courts”), and expressly agree to such forum forAND REPAIR, SHIPPED BY PREPAID AND INSURED FREIGHT the bringing of any suit, action or other proceeding arising out of theTO A LOCATION DESIGNATED BY LESSOR. IF, IN THE Lessees obligations hereunder, and expressly waive any objection toJUDGMENT OF LESSOR, THE EQUIPMENT IS RETURNED venue in any such Courts and waive any right to a trial by jury so thatDAMAGED, INCOMPLETE, OR SHOWS SIGNS OF EXCESSIVE trial shall be by and only to the Court. Lessee agrees that any processWEAR, LESSEE AGREES TO PAY THE REPLACEMENT COST served for any court action or proceeding shall be valid if mailed byAND/OR THE REPAIR AND REFURBISHING COST (INCLUDING certified mail, return receipt requested.CLEANING), FOR AN AMOUNT DESIGNATED BY LESSOR ANDPAYABLE WITHIN TEN (10) DAYS OF LESSOR’S DEMAND. (c) IF 19. SIGNED COUNTERPARTS. This Lease may be signed inLESSEE DOES NOT ELECT TO PURCHASE OR RETURN THE counterparts. Delivery of an executed counterpart of the signatureEQUIPMENT UPON EXPIRATION OR TERMINATION OF THIS page to this Lease by fax shall be effective as delivery of a manuallyLEASE AS PROVIDED IN (a) OR (b) OF THIS SECTION, THE executed counterpart of this Lease, and any failure to deliver aEQUIPMENT SHALL CONTINUE TO BE HELD AND LEASED manually executed counterpart sent by fax shall not affect the validity,HEREUNDER, AND THIS LEASE SHALL BE EXTENDED enforceability, or binding effect of this Agreement. NotwithstandingINDEFINITELY AS TO TERM AT THE SAME MONTHLY RENTAL, any other provision of this Lease to the contrary, the sole original ofSUBJECT TO THE RIGHT OF EITHER THE LESSEE OR THE this Lease for all purposes shall be the Lease bearing the manuallyLESSOR TO TERMINATE THE LEASE UPON THIRTY (30) DAYS’ executed signature of the Lessor. The Lessee, by making anyWRITTEN NOTICE, WHEREUPON THE LESSEE SHALL payment required under this Lease, ratifies all of the terms of thisFORTHWITH DELIVER THE EQUIPMENT TO LESSOR AS SET Lease.FORTH IN THIS PARAGRAPH. (d) PROVIDED LESSEE HASFULFILLED ALL OF ITS OBLIGATIONS TO LESSOR 20. IMPORTANT INFORMATION ABOUT PROCEDURES FORHEREUNDER, LESSEES SECURITY DEPOSIT, IF ANY, AS OPENING A NEW ACCOUNT. To help the government fight theINDICATED HEREIN, (1) SHALL BE REFUNDED TO LESSEE AT funding of terrorism and money laundering activities, Federal lawTHE EXPIRATION OF THE LEASE WITHOUT INTEREST; OR (2) requires all financial institutions to obtain, verify, and recordAT LESSEES DIRECTION, SUCH SECURITY DEPOSIT MAY BE information that identifies each person who opens an account.APPLIED TO THE PURCHASE OF THE EQUIPMENT, IN WHICHEVENT THE EQUIPMENT NEED NOT BE RETURNED TO 21. IMPORTANT INFORMATION ABOUT CREDIT REPORTING.LESSOR. Lessor may report information about this account to credit bureaus. Late payments, missed payments, or other defaults on this account17. ENTIRE AGREEMENT: CHANGES. This Lease contains the may be reflected in the credit report of lessee and/or guarantor.entire agreement between the parties and may not be altered,amended, modified, terminated or otherwise changed except in 22. IMPORTANT INFORMATION ABOUT PAYMENT DISPUTES.writing and signed by an executive officer of Lessor and by the Lessee agrees to contest transactions that might be invalid withinLessee. ninety days of the transaction date, otherwise the transaction will be deemed valid.18. MISCELLANEOUS. If Lessee fails to pay any rent or otheramount required herein to be paid to Lessor within five (5) days ofLADCO General Use1 Ver 2/10 Page 4 of 4 Initials_________ Date_________
  • 9. Bank Disclosure PageMember Bank InformationMerrick BankMerchant Services Department135 Crossways Park Drive North, Suite A, Woodbury, NY 11797(800) 328-9155Important Bank Responsibilities1. Merrick Bank is the only entity approved to extend acceptance of VISA products directly to a Merchant.2. Merrick Bank must be a principal (signor) to the Merchant Agreement.3. Merrick Bank is responsible for educating Merchants on pertinent VISA Operating Regulations with which Merchants must comply.4. Merrick Bank is responsible for and must provide settlement funds to the Merchant.5. Merrick Bank is responsible for all funds held in reserve that are derived from settlement.Merchant InformationMerchant Name: _______________________________________Merchant Address: _____________________________________Merchant Phone: _______________________________________Important Merchant Responsibilities1. Ensure compliance with cardholder data security and storage requirements.2. Maintain fraud and chargebacks below thresholds.3. Review and understand the terms of the Merchant Agreement.4. Comply with VISA Operating Regulations.The responsibilities listed above do not supersede terms of the MerchantAgreement and are provided to ensure the Merchant understands someimportant obligations of each party and that the VISA Member – MerrickBank - is the ultimate authority should the Merchant have any problems._________________________________ _________________Merchant’s Signature Date_________________________________Merchant’s Printed Name & Title
  • 10. MERCHANT APPLICATION APPLICATION ADDENDUM Business Name Agent No TERMINAL/SOFTWARE INFORMATION Does Merchant Use a Terminal or Software Terminal Software If Software, What is the Payment Application Name If Terminal, Brand and Model If Software, What is the Version of the Payment Application MERCHANT PRODUCT/SERVICE PROFILE Describe the Product or Service O ered How are the Items or Services Priced (ex. computer modems, $50.00 - $250.00) How is the Product Manufactured and by Whom (please list manufacturers as trade references) Where is the Product or Service Advertised or Promoted (if publication list and attach copies of each, if online list up and running www address) How is the Product or Service Ordered or Purchased (mail order, catalogue, over the phone, in person, etc) How is the Product or Service Delivered What is the Warranty, Return, and Refund Policy Note: customer can only be charged after the product has been shipped or received and after services have been rendered. OWNERS OR OFFICERS Signature VISA & MasterCard Regulations require all Retail (Not Mail Order or Phone Order) Merchants to obtain a manual imprint of all transactions in which a card is NOT swiped through an electronic processing machine or data on that card is unreadable. This includes, but is not limited to, Voice Authorizations and Key Entered (for any reason) transactions. The imprint must include at least the following information; card number, cardholder name, card expiration date, sale amount, authorization number, Merchant name, Merchant number, sale date, brief description of product or service and cardholder’s signature. Failure to secure the above listed information and imprint of a customers’ card may result in a chargeback to Merchant that may be irreversible. I have read and fully understand the above statement. I have in my possession or I am purchasing at the time of this application a manual imprinter to facilitate the above requirements. I understand and agree to provide the above listed information. Furthermore, I understand that the providing of such is my (Merchant’s) sole responsibility. Merchant hereby warrants that all statements above are true and correct. Merchant may be subject to immediate termination should it change its product or service from the descriptions on this Addendum provided to Electronic Payment Systems, LLC without prior written approval. Print Name of BusinessX X Signature Printed Name Date Signature Printed Name Date
  • 11. MERCHANT APPLICATION TERMINAL INFORMATION SHEET O ce No. Agent NameTERMINAL DOWNLOAD INFORMATIONMerchant Business Name The Merchant Will be AcceptingStreet Address Amex Amex No.City State Zip Discover Discover No.Business Phone No. ( ) Cell ( ) What Type of Transaction Will the Merchant be RunningE-mail Address Retail Only Tip Function EBT (food stamp bene ts)EQUIPMENT INFORMATION NEEDEDWhat is the Type of Equipment (please identify the type and model) Hypercom Type Nurit Type Omni Type POS System Type Gateway Check Imager Software Type Pin Pad Type OtherSHIPPING INFORMATIONWould you Like EPS to Ship Equipment Yes No Your FedEx Account No. Ship to NameHow Would you Like the Equipment to be Sent Ship to Address Overnight Second Day Air Ground Other City State ZipADDITIONAL INFORMATIONWould you Like Assistance With the Download or Assistance With the Software File Build Yes No Additional Information to Assist in Proper File Set UpComments If you Are Needing Assistance or Have any Questions Please Contact Our Agent Relations at 800-863-5995
  • 12. MERCHANT APPLICATION VOIDED CHECK WE NEED TO KNOW WHERE TO PUT YOUR MONEY FROM THE CREDIT CARD SALES!Write VOID across a check from the account you would like the funds to be depositedin! Do not use a starter check or a bank deposit ticket, it must be a check with your name and address on it. YOUR MONEY WILL BE DEPOSITED DIRECTLY INTO THIS ACCOUNT! ATTACH VOIDED CHECK HERE
  • 13. MERCHANT APPLICATION ATTACHMENT REMINDERWE NEED A FEW MORE DOCUMENTS! A copy of the merchant’s Business License A copy of the merchant’s Drivers License A copy of one months Credit Card Statement
  • 14. Attestation of Compliance, SAQ BInstructions for SubmissionThe merchant must complete this Attestation of Compliance as a declaration of the merchant’s compliance statuswith the Payment Card Industry Data Security Standard (PCI DSS) Requirements and Security AssessmentProcedures. Complete all applicable sections and refer to the submission instructions at “PCI DSS Compliance –Completion Steps” in this document. Part 1. Qualified Security Assessor Company Information (if applicable) Company Name: Lead QSA Contact Title: Name: Telephone: E-mail: Business Address: City: State/Province: Country: ZIP: URL: Part 2. Merchant Organization Information Company Name: DBA(S): Contact Name: Title: Telephone: E-mail: Business Address: City: State/Province: Country: ZIP: URL: Part 2a. Type of merchant business (check all that apply): Retailer Telecommunication Grocery and Supermarkets Petroleum E-Commerce Mail/Telephone-Order Others (please specify): List facilities and locations included in PCI DSS review: Part 2b. Relationships Does your company have a relationship with one or more third-party service providers (for example, gateways, web- hosting companies, airline booking agents, loyalty program agents, etc)? Yes No Does your company have a relationship with more than one acquirer? Yes No Part 2c. Transaction Processing Payment Application in use: Payment Application Version:PCI DSS SAQ B, v1.2, Attestation of Compliance October 2008Copyright 2008 PCI Security Standards Council LLC Page 2
  • 15. Part 3b. Merchant Acknowledgement Signature of Merchant Executive Officer Ç Date Ç Merchant Executive Officer Name Ç Title Ç Merchant Company Represented ÇPCI DSS SAQ B, v1.2, Attestation of Compliance October 2008Copyright 2008 PCI Security Standards Council LLC Page 4
  • 16. $0(5,&$1 ( ;35(66 & $ 5 Establishment Services $&&(37$1&( $ 33/,&$7,21The Shaded Box Will Be Completed By The Sales Agent ESA Corporate Name: Sales Agent ID # Please check one of the following: Paper . % Monthly Gross Pay American Express Discount Rate* EDC Home Based ( + .03% if $100K + ) . % or or Daily Gross Pay American Express Monthly Flat Fee - $5.00* Yes No 3 15 30 Estimated $ Estimated $ Pay Day Day Day Annual American Express Charge Volume Average Ticket Frequency Franchise Name: Franchise CAP #: * Applies to online statements. Paper statements may be subject to additional fees.What Is Your Name & Address? Please Complete The Following. If You Have Any QuestionsCall 1-800-528-5200 FULL LEGAL NAME of Corporation, Partnership or Proprietorship Doing Business As (DBA, Trade Name) Address City State Zip Code Federal Tax ID (TIN/EIN) ACH ABA# DDA# URL E-mail Signer Information Name: Title: Social Security Number: Home Address: City: State: Zip: Have You Previously Had An American Express Merchant Account #: Yes No If Yes, Merchant #: By signing below, I represent that the information I have provided on the Application is complete and accurate and I authorize American Express Travel Related Services Company, Inc. ("American Express") to verify the information on this Application and to receive and exchange information about me, including, requesting reports from consumer reporting agencies. If I ask American Express whether or not a consumer report was requested, American Express will tell me, and if American Express received a report, American Express will give me the name and address of the agency that furnished it. I understand that upon American Express’ approval of the business entity indicated above to accept the American Express Card, the Terms and Conditions for American Express ® Card Acceptance ("Terms and Conditions") will be sent to such business entity along with a Welcome Letter. By accepting the American Express Card for the purchase of goods and/or services, you agree to be bound by the Terms and Conditions. Please Sign Here X Date: MARGINALS ESA7697 (Rev. 5/03)
  • 17. MERCHANT APPLICATION RECEIPT FORM Phone: 800.863.5995 Fax: 303.694.0155 MERCHANT INFORMATION Name Title Street Address Doing Business As City State Zip E-mail Address Business Phone No. ( ) Cell ( ) RECEIPT PRODUCTS/SERVICES/FEES COMMENTS Registration Fee - - - - - - - - - - - - - - - - - $ Programming Fee - - - - - - - - - - - - - - - - $ Download Fee - - - - - - - - - - - - - - - - - - $ Setup Fee - - - - - - - - - - - - - - - - - - - $ Lease - - - - - - - - - - - - - - - - - - - - - $ x Months Discover Card Acceptance - - - - - - - - - - - - - $ Debit Network Setup - - - - - - - - - - - - - - - $ Additional Locations - - - - - - - - - - - - - - - $ Manual Imprinter - - - - - - - - - - - - - - - - $ Supplies - - - - - - - - - - - - - - - - - - - - $ Signage and Marketing Materials - - - - - - - - - - $ TOTAL $ PAID WITH APPLICATION $ BALANCE DUE $ RECEIPT SIGNATURE By signing below Merchant and individual acknowledge receipt of this form and agree to the terms and conditions referenced to herein. Furthermore Merchant acknowledges that for each service noted above they have received and accepted the terms and conditions related to those items, products, and/or services.X X Signature Printed Name Date Signature Printed Name Date

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