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Credit Card Processing Questions ISO NAME: _______________ 100 Jericho Quadrangle 36-36 33rd St., Ste 306 Long Island City,NY 11106 Ste 100, Jericho, New York 11753 ISO # ______________ Phone: (866)811-1005 Fax: (800)455-4126 MCC # _____________ CREDIT CARD PROCESSING QUESTIONS DATE (mm/dd/yy)_____________ CORPORATE NAME (INC/CORP/LLC) _______________________________________________________ DBA NAME (SAME AS ON CC RECEIPT) ____________________________________________________ BUSINESS ADDRESS ____________________________________________________________________ CITY ________________________________________ STATE ___________________ ZIP_____________ TEL _________________ FAX ________________ EMAIL _______________________________________ WEBSITE _________________________________ TYPE OF OWNERSHIP _________________________ TAX ID __________________ DATE BUSINESS STARTED (mm/yy) _______________ STATE _________ OWNER NAME ______________________________________________ SS# _______________________ HOME ADDRESS ____________________________________________ TEL _______________________ CITY ________________________________________ STATE ___________________ ZIP_____________ DATE OF BIRTH (mm/dd/yy)_____________ DRIVER LIC# _________________ STATE ______________ BANK NAME ___________________________________ ACCOUNT (DDA) # _______________________ ROUTING (ABA) # _______________________________ MANAGER ______________________________ ACCEPT AMEX YES? NO? NEW AMEX# YES? EXISTING? EXISTING AMEX # ____________________ DEBIT (PINPAD) YES? EBT (FNS) # ___________ (AMEX) ________ GROSS YEARLY SALE (CREDIT/DEBIT) ___________ YEARLY TOTAL (MC/VISA) ________ (DISCOVER) ________ AVERAGE PURCHASE TICKET _______________ HIGHEST PURCHASE TICKET __________________ PRODUCTS OR SERVICES SOLD ________________________________ SWIPED: _______ % MOTO/KEYED: _______ % INTERNET: _______ % AUTO CLOSE?: Yes NO IF YES: TIME _______ MCC/SIC CODE ___________________ BUSINESS TYPE: _______ _____________ Please, provide a voided copy or a check bearing your company’s name ISO NAME: _______________ MERCHANT PROCESSING ISO # ______________ 36-36 33rd St., Ste 306 100 Jericho Quadrangle APPLICATION & AGREEMENT Long Island City, NY 11106 Ste 100, Jericho, New York 11753 MCC # _____________ BUSINESS INFORMATION Business Legal Name (must match name on tax return): Business D/B/A: (“MERCHANT”) Legal Address: DBA Address (Physical Address): Legal City: Legal State: Legal Zip: DBA City: DBA State: DBA Zip: Contact Name: Phone: Email: Fax: BUSINESS PROFILE AND ASSUMPTIONS Fed. Tax ID: Ownership Type: Type of Business: Business Open Date: # of Employees: Highest Ticket ($): Annual Visa/MasterCard/Discover/ Average Ticket ($): AXP Card Swipe Moto/Keyed Internet = TOTAL Volume ($): : 100% % + % + % Total must not exceed 100% Type of Goods/Services sold: (Please include a copy of your return/refund policy) Business Website: SITE INSPECTION SURVEY Inventory maintained: On site Warehouse off site Fulfillment center Please provide fulfillment center name & address ________________________________________________________________________________________________ Was the off site location visited? Yes No If No, please provide explanation: _____________________________________________________________________ Does the amount of inventory on shelves, floor and in warehouse appear consistent with this type of business and credit card volume? Yes No If no, please explain: ___________________________________________________________________________________________________________ Does location have sufficient staff, telephone lines and other equipment to meet anticipated sales volume? Y es No If no, please explain: ______________________________________________________________________________________________________ Does the signage inside and outside match the goods or services sold listed on the application? Yes No If no, please explain:_____________________________________________________________________________________________________ Type of Building: Office Bldg. Suit e Separate B l dg Shopping Center/Mal l Residence-Home or Apt. Other:_______________________________________________________ Zoning: Commercial Industrial Residential Sq. Footage of Business: 0-50 0 501-1000 1001-2000 2001-4000 Other :____________________________________________________________________ Merchant: Owns Leases Name & address Landlord / Mgt Co:_______________________________________________________________________________________ ATTACH MINIMUM OF ONE INSIDE PICTURE, ONE OUTSIDE PICTURE. I hereby verify that I have inspected the business premises of the merchant at this address and the information stated above is correct to the best of my knowledge and belief. Inspected By (Print Name):_________________________________________________ Signature:__________________________________________________ Date: _______________________________ DDA: ABA: Bank name: In accordance with the terms set out in the Terms and Conditions, standard transfer funds will be made to/from the account set forth in the enclosed voided check or bank letter. REFERENCES Bank Reference Name: Contact: Phone: Account Number: Trade/Supplier Name: Contact: Phone: Account Number: BANK DISCLOSURE MEMBER BANK Important Bank Responsibilities: Important Merchant Responsibilities: (ACQUIRER) Esquire Bank is the only entity approved to extend acceptance of VISA products directly INFORMATION 1. 1. Ensure compliance with cardholder data security and storage to a Merchant. ESQUIRE BANK requirements. Esquire Bank must be a principal (signor) to the Merchant Agreement. 100 Jericho Quadrangle 2. 2. Maintain fraud and chargebacks below thresholds. Esquire Bank is responsible for educating Merchants on pertinent VISA Operating Ste 100 3. 3. Review and understand the terms of the Merchant Jericho, New York 11753 Regulations with which Merchants must comply. Agreement. Esquire Bank is responsible for and must provide settlement funds to the Merchant. 516-535-2002 4. 4. Comply with VISA Operating Regulations. 5. Esquire Bank is responsible for all funds held in reserve that are derived from settlement. The responsibilities listed above do not supersede terms of the Merchant Agreement and are provided to ensure the Merchant understands some important obligations of each party and that the VISA Member—Esquire Bank—is the ultimate authority should the Merchant have any problems. MERCHANT / Title: Authorized Signature: Date: (OWNER) Print: X Address: City: State: Zip: MI V 2.1 NOV 17 Swipe4Free is a registered agent of ESQUIRE BANK 100 Jericho Quadrangle, Suite 100, Jericho, New York 11753 Page 1of 2 2017 Merchant Application FEES CREDIT DEBIT Package:________________ Other:__________ % Pass Through Pin Debit Network Fees: Pin Debit Auth: Other Item Rate: Other Volume Rate: YES NO $_______ (Per Item) $_______ (Per Item) _________% Invalid TIN Fee: Voice AVS Fee: ARU Fee: Annual Fee: Retrieva l Fee (12B Letter): Chargeback Fee: NSF Fee $ $_______ (Per Item) $________ (Per Item) $_________ $________ (Per Item) $________ (Per Item) $25 EBT Food Stamps #:___________________ EBT Authorization: Minimum Monthly Fee: Wireless Fee: Membership Fee Collection Fee $________ (Per Item) *EBT Addendum Required $_______ (Per Item) $_________ $_________ $____________ 20% - (Uncollected Amount) PCI PCI Validation: $119.99 per year PCI Non Validation: $19.95 per month Breach protection:$______ /month Chargeback Insurance $______ /month EQUIPMENT/SOFTWARE PAX S80 DEJAVOO IWL 250 (Wireless) MOBILE SWIPER VIRTUAL TERMINAL OTHER Model:_______________________ Quantity:_____________________ NOTESS. Dial IP Dial IP Quantity:_____________ Dial IP Quantity:_____________ Quantity:_____________ Quantity:_____________ Quantity:_____________ Recurring Payments Quantity:_____________ New Existing New Existing New Existing New Existing Quickbooks Integration New Existing Pin Pad: Quantity: New Existing Notes: EARLY TERMINATION FEE AGREEMENT In the event that MERCHANT terminates this Agreement MERCHANT shall be liable to pay to ISO an EARLY TERMINATION FEE. The EARLY TERMINATION FEE shall be equivalent to the greater of (a) $750; or (b) number of whole months remaining in the TERM hereof at the time of termination multiplied by the amount of FEES paid or payable by the MERCHANT during the month preceding that during which this AGREEMENT was terminated. MERCHANT agrees that this fee is not a penalty, but rather a reasonable estimation of the actual damages that would be suffered in the event of failure to receive the processing business for the then current term. MERCHANT agrees that the EARLY TERMINATION FEE shall also be due if MERCHANT discontinues submitting SALES for processing during the INITIAL TERM or any RENEWAL TERM of the AGREEMENT. The amount of the EARLY TERMINATION FEE maybe deducted from settlements payable to the MERCHANT under this Agreement. Paragraph references and capitalized terms not defined in this paragraph are defined in the attached Terms and Conditions. PERSONAL GUARANTEE In consideration of Bank’s acceptance of this Agreement, the undersigned Guarantor (jointly and severally if more than one) unconditionally guarantees the performance of all obligations of Merchant to Bank under the Agreement, and payment of all sums due there under, and in the event of default, hereby waives notice of default and agrees to indemnify Bank for all funds due from Merchant pursuant to the terms of the Agreement. Guarantor waives any and all rights of subrogation, reimbursement or indemnity derived from Merchant, and further waives
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