ATTN: New Accounts Department

Front Cover Sheet

Business (DBA): PLEASE DISREGARD THIS PAGE, FAX TO 469-675-8740 Contact First Name: Contact Last Name: Business Address: City: Province: Postal Code: Business Phone #: Rep Number: 23630

ATTN: New Accounts Department 888-245-7153 [email protected] Required for every app Complete Merchant Application – Signed application reflecting the current ownership. Complete Merchant Application Sales Worksheet (1 page) Sales rep must also sign the submitted by line PG (Personal Guarantee) or Business Financials o Anytime a PG is signed, a SSN is required. o If a Personal Guarantee is not obtained – Most current year 3rd Party (reviewed or audited) Financial Statements**. If financials are not prepared by a 3rd Party, Financial Statements must be accompanied with the same years Federal Income Tax Return o Exception – Furniture merchants must provide 2 years 3rd Party prepared Financial Statements. Business Verification – Acceptable proof of existence shall include, but not be limited to, one of the following: o 3 months of CURRENT processing statements o Photos of the business site o Yellow Page advertisement o Business License o 3rd party prepared business financials or tax returns o 12 months of checking account history o Phone Bill or Utility Bill o Articles of Incorporation o Copy of Federal Tax ID paperwork o Professional License o Sales and Use Tax o Copy of Federal Tax Identification paperwork o Business Tax Receipt o Internet website registered to merchant o Business credit bureaus report o IRS Fom 1099 o Proof of Tax-Exempt status o Lease Agreement between merchant and landlord, as long as the entity and address match lease agreement

Additional requirements as needed

Additional Requirements for Card Not Present Merchants o 3 months of CURRENT all pages processing statements if currently processing

Additional Requirements for an Internet Merchant o Same Additional Requirements as card not present merchant o Internet Requirements o Company’s name must be displayed on the website o Clear posting of the merchant’s Customer Service Telephone Number / email address o Refund/Return policy o Delivery methods and timing o Privacy policy o Products/Service prices listed o Secure Checkout page o Domain registered to merchant (in US/Canada only)

Additional Requirements for a Non-Profit Merchant o Proof of tax exempt status (501-C3) US / Letter of Patent (Canada)

** Business Financial Require – Balance Sheet, Income Statement, Statement of Cash Flow & Financial Notes. As indicated in General Credit Policy 375-1, Small Merchant Policy 375-2, and Large Merchant Policy 375-3.

N E W M E R C H A N T A P P L I C A T I O N

MERCHANT INFORMATION 1 DBA NAME: DBA PHONE #:

CORPORATE NAME (IF DIFFERENT THAN ABOVE): DBA FAX #:

CONTACT NAME: CUSTOMER SERVICE PHONE #:

DBA ADDRESS 1 (NO PO BOX): PREVIOUS PROCESSOR:

DBA ADDRESS 2: YEAR ESTABLISHED:

CITY: PROVINCE: POSTAL CODE: LENGTH OF CURRENT OWNERSHIP: YEARS, MONTHS

BUSINESS COUNTRY OF ORIGIN (HEADQUARTERED):

GEOGRAPHY FOOTPRINT (ALL COUNTRIES LICENSED TO DO BUSINESS): CAN,

BUSINESS SCOPE OF OPERATIONS (TOTAL NUMBER OF LOCATIONS IN ALL COUNTRIES INCLUDING CAN):

EMAIL ADDRESS*: MOBILE PHONE #*:

* By providing your mobile phone number and/or e-mail address, you expressly authorize Elavon to use that information to contact you about your account and to market additional products/services to you. You are not required to provide your mobile phone number and/or e-mail address in connection with this Merchant Application and if you do, you may elect in the future not to receive such communications from Elavon by following the opt out procedures set forth in your Agreement.

OTHER ADDRESS (IF DIFFERENT THAN ABOVE) 2 MAILING SHIPPING SEE ALSO SPECIAL INSTRUCTIONS

DBA NAME: PHONE #:

CONTACT: FAX #:

ADDRESS: CITY: PROVINCE: POSTAL CODE:

PRINCIPAL 1 INFORMATION (INCLUDE ALL ADDITIONAL OWNERS WITH 25% OR GREATER OWNERSHIP ON THE ADDITIONAL OWNERSHIP FORM) 3 BENEFICIAL OWNER: PERCENTAGE OF OWNERSHIP AUTHORIZED SIGNER PERSONAL GUARANTOR ONLY

FIRST NAME: MIDDLE NAME: LAST NAME:

HOME ADDRESS: DOB: SIN:

CITY: PROVINCE: POSTAL CODE: HOME PHONE #:

PREVIOUS ADDRESS IF CURRENT ADDRESS IS LESS THAN 2 YEARS

HOME ADDRESS: CITY: PROVINCE: POSTAL CODE:

SOLE PROPRIETORS ONLY

OCCUPATION: EMPLOYER (OR DBA)

COUNTRY OF PERMANENT RESIDENCE: COUNTRY(S) OF CITIZENSHIP: OTHER MERCHANT INFORMATION

AVERAGE SALE AMOUNT: $ DESCRIPTION OF PRODUCT OR SERVICES OFFERED:

TOTAL MONTHLY VISA/MC/DISC/UNIONPAY SALES: $ MCC:

CARD PRESENT (SWIPED) % WHEN DOES THE CUSTOMER RECEIVE THE PRODUCT OR SERVICE?

CARD PRESENT (NOT SWIPED) % SAME DAY IF NOT SAME DAY, # OF DAYS (INCLUDE SHIPPING TIME FRAME)

INTERNET % IS ANY PRODUCT DELIVERY OVER 1 YEAR? YES NO

FOR INTERNET TRANSACTIONS: TOTAL = 100% LIST THE PRODUCT WEB SITE:

DO YOU OPERATE SEASONALLY: YES NO IF YES, PLEASE CHECK MONTHS CLOSED (MERCHANT MUST NOTIFY TO CLOSE AND REOPEN)

JANUARY FEBRUARY MARCH APRIL MAY JUNE

JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER VALUE ADDED SERVICES

VALUE ADDED SERVICES (COMPLETE NEW MERCHANT APPLICATION – VALUE ADDED SERVICE SECTION) FOR SALES USE ONLY

NEW LOCATION ADDITIONAL LOCATION EXISTING MID: CHAIN #: LOCATION 1 OF 1

AWB: REP NAME: Linnay Zazueta REP #: MSP SHORT NAME: CAN00NXG

FI: 0925 AGENT: 23630 BANK: 0024 CLIENT GROUP #: 24 ENTITY: 40199

STATEMENTS: DBA OR MAILING OR W-9 AUTO SEND: YES NO (CHAIN MERCHANTS ONLY – MUST INCLUDE CHAIN SET UP FORM)

______Initials 2 CAN-MSP-ELV-1115 RETRIEVALS: MAIL TO: DBA MAILING OR FAX TO: DBA MAILING OR EMAIL TO: OR ONLINE CASE MANAGEMENT (OCM) CHARGEBACKS: MAIL TO: DBA MAILING AND FAX TO: DBA MAILING OR EMAIL TO: OR ONLINE CASE MANAGEMENT (OCM)

CARD ACCEPTANCE (PLEASE CHECK EACH CARD YOU WISH TO ACCEPT.) PRICING CATEGORY

ALL VISA/MASTERCARD/UNIONPAY/DISCOVER CARDS (DI, BC CARD, DINACARD) RETAIL RESTAURANT ARU

VISA CREDIT VISA DEBIT MASTERCARD CREDIT MASTERCARD DEBIT DISCOVER (DI, BC CARD, DINACARD) MOTO INTERNET UNIONPAY PRICING INFORMATION FEES RATES ARE FOR ALL CARD ACCEPTANCE TYPES SELECTED. ALL CARD BRAND ASSESSMENTS WILL BE PASSED THROUGH AT COST. APPLICATION FEE $45

TIERED VISA MASTERCARD DISCOVER UNIONPAY INSTALLATION/TRAINING $ OR RETURN ITEM FEE/NSF RATE (%) + PER ITEM ($) RATE (%) + PER ITEM ($) RATE (%) + PER ITEM ($) RATE (%) + PER ITEM ($) (PER OCCUR) $25 ENHANCED IC PLUS QUALIFIED 1.75 % + $ 1.75 % + $ 1.75 % + $ 1.75 % + $ CHARGEBACK (PER OCCUR) $10 MID QUALIFIED 2.30 % + $ 2.30 % + $ 2.30 % + $ 2.30 % + $ ACCOUNT MAINTENANCE $25

NON QUALIFIED 2.30 % + $ 2.30 % + $ 2.30 % + $ 2.30 % + $ MONTHLY SERVICE FEE $6 OTHER TIER - DEBIT MONTHLY MINIMUM (T-opt / EIC-req) % + $ % + $ % + $ % + $ $10

REWARDS TIER INTERAC MONTHLY MINIMUM (T-opt / EIC-req) 2.30 % + $ 2.30 % + $ 2.30 % + $ 2.30 % + $ $

COMMERCIAL CARD TIER COMBINED MONTHLY % + $ % + $ % + $ % + $ $ (T-opt /EIC-req) MINIMUM

ANNUAL FEE CANADIAN DEBIT QUAL $ (T-opt / EIC-req) % + $ % + $ START DATE: Monthly PCI Compliance Fee $8.50 Other Fees May Apply, See Merchant VISA MASTERCARD DISCOVER UNIONPAY PASS THRU: Application

IC PLUS OTHER $ RATE (%) + PER ITEM ($) RATE (%) + PER ITEM ($) RATE (%) + PER ITEM ($) RATE (%) + PER ITEM ($) OR IC DIFF OTHER $ OTHER $ MARKUP % + $ % + $ % + $ % + $ OTHER $

AUTHORIZATIONS PRICING PROGRAMS

VISA $0.15 UNIONPAY $0.15 VOICE AUTH TOUCH TONE $0.65 MONETARY PRICING PROGRAM:

MASTERCARD $0.15 FOREIGN NETWORK $0.15 VOICE- OPERATOR ASSISTED $0.95 AUTH PRICING PROGRAM:

DISCOVER (DI, BC CARD, DINACARD) $0.15 OTHER $ VOICE – WITH AVS $ EQUIPMENT: 59999

AMEX $ OTHER $ VOICE – BANK REFERRAL $ MISCELLANEOUS: 69999 PIN DEBIT PIN DEBIT SURCHARGE

DEBIT PRICING: PASS THROUGH (INTERCHANGE + MARKUP-ICDIF) Pass through (Interchange + Markup - ICPLS)

SURCHARGE (FLAT RATE) 33 % DEBIT AUTHORIZATION PRICING: PASS THROUGH (INTERCHANGE + MARKUP) FIXED (FLAT RATE)

INTERAC: NA % $NA AUTH: $NA

BANK ACCOUNT (CHEQUING ACCOUNTS ONLY)

DEPOSIT BANK NAME: TRANSIT #: DDA ACCOUNT #:

BILLING/CHARGEBACK BANK NAME (IF DIFFERENT): TRANSIT #: DDA ACCOUNT #: POINT OF SALE (EQUIPMENT OR SOFTWARE)

NETWORK: ELAVON OTHER # OF TIDS (VAR):

VAR SERVICE PROVIDER (HOSTED): VAR VENDOR (DISTRIBUTED): ACH Direct/Forte GATEWAY (OPTIONAL): ACH Direct/Forte VAR PRODUCT: Payments Gateway VAR VERSION: 3 AGGREGATOR:

MONTHLY PURCHASE PRICE RENTAL TERM QTY POS DESCRIPTION EQUIP. CODE TRAINING RENTAL RATE PURCHASE RENTAL EXISTING PER UNIT MONTHS PER UNIT $ $ $ $ $ $ $ $ ______Initials 3 CAN-MSP-ELV-1115 SERVICED BY: CONTACTLESS ALL APPLICABLE STATE AND LOCAL TAXES WILL BE APPLIED

SATURDAY DELIVERY NEXT DAY AIR 2ND DAY AIR ELAVON BILLS ONE TIME FEES MSP BILLS ONE TIME FEES OTHER CARD TYPES EXISTING SE # AUTH FEE SE # AUTH FEE AMEX (10 DIGITS) $ OTHER: $ REPORT TOOLS MCP ONLY OR MCP WITH OCM MONTHLY FEE $ SET UP FEE $ # USERS SET UP TYPE (CHECK ONE) MID CHN ENT ACS MONTHLY FEE $ SET UP FEE $ REMOTE ID

GST AND Form W-8BEN (Non-US Entities/Citizens/Residents)

GST TAX ID: The W-8BEN form establishes your non-US status. (Partnerships and US Entities/Citizens/Residents require additional documentation. Discuss with your sales representative.) Beneficial owner and residence address below should reflect that of the business’ legal entity. For Individuals/Sole Proprietors, this should always be the owner’s information (name and address). For definitions of beneficial owner and permanent residence address, see below. Individual/Sole Proprietor Corporation Disregarded Entity Partnership (additional paperwork required) Simple Trust Grantor Trust Complex Trust

Estate Government International Organization Central Bank of Issue Tax-exempt organization Private Foundation BENEFICIAL OWNER (OWNERSHIP): COUNTRY OF INCORPORATE OR ORGANIZATION:

PERMANENT RESIDENCE ADDRESS (NO PO BOXES OR IN-CARE-OF ADDRESSES):

CITY, PROVINCE, POSTAL CODE COUNTRY (DO NOT ABBREVIATE):

MAILING ADDRESS (IF DIFFERENT THAN ABOVE):

CITY, PROVINCE, POSTAL CODE COUNTRY (DO NOT ABBREVIATE): 5 MERCHANT REPRESENTATIONS AND CERTIFICATIONS Merchant Representations and Certifications. By signing below, the applicant merchant All merchants must comply with the requirements of the Payment Card Industry Data Security Standards (“Merchant”) and its representative(s) represent and warrant to Elavon Canada Company, (“PCI DSS”). Elavon requires Level 4 merchants (determined based on Transaction volume) to validate doing business as Elavon Canada (“Elavon”), U. S. Bank National Association Canada PCI DSS compliance on an annual basis, with initial validation to occur no later than ninety (90) days branch (“VISA Member”), if we provide VISA services to you, Elavon Canada Company ("MasterCard after account approval. Any merchant that has not validated PCI DSS compliance within ninety (90) days Member"), if we provide MasterCard services to you, Elavon Canada Company (“Discover Member”), of account approval, or in subsequent years on or before the anniversary date of account approval, will if we provide Discover services to you, and Elavon Canada Company (“Union Pay Member”), if we be charged a monthly non-compliance fee of $20.00 until Elavon is provided with validation of provide Union Pay services to you. (VISA Member, MasterCard Member, Discover Member, and compliance. Merchant may be eligible for Data Breach Coverage following account approval and PCI Union Pay Member shall each be referred to as a "Member", collectively the "Members", and Elavon DSS compliance validation. and the Members shall be collectively referred to as “we”, "our" or “us”) that (i) all information Merchant, its representative(s) and each person whose information is on this Merchant Application provided in this merchant application (“Merchant Application”) is true and complete and properly authorizes us prior to our acceptance of this Merchant Application and from time to time thereafter, for reflects the business, financial condition, and principal partners, owners, or officers of Merchant; and the purposes of facilitating the provision of our services to Merchant, to (i) investigate the individual and (ii) the persons signing this Merchant Application are duly authorized to bind Merchant to all business history and background of Merchant, each such representative, each such person and any provisions of this Merchant Application and the Agreement. Further, by signing below, if leasing other officers, partners, proprietors, and/or owners of Merchant (collectively, the "Merchant Parties"); (ii) equipment, Merchant and its representative(s) agree that the Leased Equipment is subject to the obtain credit reports, financial information or other background investigation reports on each of the terms and conditions set forth in the Terms of Service (“TOS”) and have had an opportunity to review Merchant Parties from our affiliates, credit agencies, other financial institutions and references provided such terms. The signature by an authorized representative of Merchant on the Merchant Application, by the Merchant Parties that we consider necessary to review the acceptance and continuation of this or the transmission of Transaction Receipt or other evidence of a Transaction to us, shall be the Merchant Application; (iii) use any personal information provided by the Merchant Parties in this Merchant’s acceptance of and agreement to the terms and conditions contained in the Agreement Merchant Application or otherwise or obtained by us under any other provision of this paragraph to including, without limitation, this Merchant Application, the TOS and the Merchant Operating Guide respond to any further application for our services; (iv) facilitate the provision of our services by sharing (“MOG”) each of which is incorporated herein by this reference and located at our website at such personal information and the results of our enquiries or investigations with our third party service https://www.merchantconnect.com/CWRWeb/pdf/TOS_ENG.pdf and providers, credit and debit card issuers, credit and debit card associations, credit agencies, governmental https://www.merchantconnect.com/CWRWeb/pdf/MOG_Eng.pdf, respectively. If Merchant does not taxation authorities and similar parties; (v) use such personal information to investigate potentially have access to view the TOS or MOG at our website please contact our merchant customer service fraudulent or questionable activities regarding the Merchant's account(s) or the use of our services; (vi) centre at 1-866-310-3345. Merchant agrees to comply with the Agreement and all applicable laws, use such personal information for reporting purposes under credit or debit card association rules or rules, and regulations including the rules and regulations of the Payment Networks, and understands regulations and to debit and credit card issuers, financial institutions or other credit or debit card related that failure to comply will result in termination of processing services. Capitalized terms shall, unless entities; (vii) use such personal information to offer products and services to the Merchant Parties that otherwise defined in this Merchant Application, have the same meaning ascribed to them in the TOS might be beneficial; (viii) use or disclose such personal information in the course of any actual or and MOG. potential sale, reorganization, amalgamation or other change to our business; and (ix) collect, use and Merchant agrees to establish and maintain sufficient funds in a designated bank account to disclose such personal information when required or permitted by law. accommodate all transactions including, but not limited to, Chargebacks, returns, adjustments, fees, The parties hereby acknowledge that they have required the Agreement and all related documents to be fines, penalties and any other payments due under the Agreement. In addition to the fees set forth in drawn up in the English language. Les parties reconnaissent avoir demandé que les présents contrats the Merchant Application, you will pay fees to Elavon at the then current rates for account ainsi que les documents qui s’y rattachent soient rédigés en langue anglaise. maintenance (e.g., dda/dba changes), special processing, retraining, equipment swaps and research including, but not limited to, research required to respond to any third party or government subpoena, By signing below, Merchant represents and warrants that it has obtained and read in full the TOS and the levy or garnishment on your account. Merchant authorizes us to credit/debit such account as MOG available at https://www.merchantconnect.com/CWRWeb/pdf/TOS_ENG.pdf and necessary to effect all such payments, agrees that all such debits are pre-authorized debits for https://www.merchantconnect.com/CWRWeb/pdf/MOG_Eng.pdf or available from our customer service business purposes as defined under Rule H1 of the Canadian Payments Association Rules and centre at 1-866-310-3345 prior to signing this Merchant Application and that it agrees with the terms agrees to hereby waive the right to receive advance notice from us of any and all debits made by us thereof. from such account or any other account maintained by Merchant at any financial institution. The Merchant Parties also authorize any person or credit reporting Merchant understands that we may take any or all of the following actions if considered necessary by us to protect ourselves from financial loss: establish, or require Merchant to establish, a reserve agency to compile information to answer credit inquiries made by account; impose a processing limit or cap on the dollar amount of sales transactions that we will us and to furnish that information to us. process for Merchant, which may be changed from time to time with or without notice to Merchant; establish holdback periods on payments to be made to Merchant; and/or suspend the processing of As it pertains to Form W8BEN, under penalties of perjury, I declare that I have examined the sales drafts for as long as necessary to investigate suspicious, unusual or excessive deposit or information on this form and to the best of my knowledge and belief it is true, correct, and transaction activity. complete. I further certify under penalties of perjury that: Merchant understands that an authorization code is not a guarantee of acceptance or payment of a 1. I am the beneficial owner (or am authorized to sign for the beneficial owner) of all the income Transaction. Receipt of an authorization code does not mean that merchant will not receive a to which this form relates Chargeback for that Transaction. 2. The beneficial owner is not a US person 3. The income to which this form relates is (a) not effectively connected with the conduct of a This Merchant Application may be signed in one or more counterparts, each of which shall constitute trade or business in the United States, (b) effectively connected but is not subject to tax under an an original and all of which, taken together, shall constitute one and the same Merchant Application. income tax treaty, or (c) the partner’s share of a partnership’s effectively connected income, and Delivery of executed counterparts of this Merchant Application may be accomplished by a facsimile 4. For broker transactions or barter exchanges, the beneficial owner is an exempt foreign person transmission, and a signed facsimile or copy of this Merchant Application shall constitute a signed as defined in the instructions. original. Furthermore, I authorized this form to be provided to any withholding agent that has control, receipt, or custody of the income of which I am the beneficial owner or any withholding agent that can disburse or make payments of the income of which I am the beneficial owner. The Internal Revenue Service does not require your consent to any provisions of this document other than the certifications required to establish your status as a non-US person and, if applicable, obtain reduced rate of withholding. SIGNATURE: X PRINTED NAME: TITLE: DATE:

SIGNATURE: X PRINTED NAME: TITLE: DATE: PERSONAL GUARANTY 6 As a primary inducement to us to accept this Merchant Application, the undersigned Guarantor(s), by signing the Merchant Application, jointly and severally, and in Quebec solidarily, unconditionally and irrevocably, guarantee the continuing full and faithful performance and payment by Merchant of each of Merchant's duties, debts, liabilities and obligations to us (including, without limitation, in respect of Chargebacks and obligations in connection with Leased Equipment, if applicable) pursuant to the Merchant Application and Agreement, as may be amended from time to time, with or

______Initials 4 CAN-MSP-ELV-1115 without notice (collectively, the "Obligations"). Guarantor(s) agrees that this is a continuing guarantee and that Guarantor's(s') liability will not be discharged, affected or released by (a) any event which results in Merchant not being under a legal obligation to make any payment or perform any Obligation, or (b) any event which results in Guarantor(s) not being under a legal obligation to make any payment or perform any obligationN hereunderE W including M byE theR Guarantor’s(s') C H A death N T or legal A incapacity.P P LGuarantor(s) I C A understand T I O further N that - we Vmay Aproceed L Udirectly E against A Guarantor(s)D D E Dwithout Sfirst Eexhausting R V our I Cremedies E S against any other person or entity(This responsible page therefore of the toNew them Merchant or any security Application held by us or isMerchant. only required Guarantor(s) when renounces enrolling the benefit for the of discussion Value Added and division. Services This guarantee listed below.)will bind all heirs, administrators, estate trustees, representatives, permitted successors and assigns of Guarantor(s) and may be enforced by or for the benefit of any of our successors. Guarantor(s) understand that the inducement to us to acceptMERCHANT this Merchant INFORMATION Application is consideration for the guarantee and that this guarantee remains in full force and effect even if the Guarantor(s) receive no additional benefit from the guarantee. Each of this guarantee, the Merchant Application and the Agreement is a business agreement and any limitation period is expressly excluded and waived entirely. Guarantor(s) acknowledges that this guarantee is a summaryDBA NAME of :the guarantee provisions in the TOS (defined above), agrees that this guarantee is subject to the terms and conditions set forth in the TOS and, by signing below, represents and warrants that it has obtained and read in full the TOS available at https://www.merchantconnect.com/CWRWeb/pdf/TOS_ENG.pdf or available from our customer service centre at 1-866-310-3345 prior to signing below and that it agreesCONTACT with N theAME terms: thereof. DBA PHONE #:

TheDBA AundersignedDDRESS 1 (NO PO hereby BOX): authorizes any credit reporting agency or bureauDBA to AfurnishDDRESS 2: us upon our request with a credit bureau report that relates to the undersigned. CITY: PROVINCE: POSTAL CODE: SIGNATURE: X PRINTED NAME: DATE: ARDS RICING SEGCIGNATURE C : X EGCPRINTED P NAME: DATE: CARD STYLE CARD QUANTITY PRICE TRANSACTION PRICING: $ PER TRANSACTION AND $ PER MONTH. STANDARD $ OR SUBMITTED BY (SALES USE ONLY) To the best of my knowledge, I certify that the information provided in this Merchant Application was provided by the Merchant and is true, complete and accurate. I further certify that the signatures were provided CUSTOM by the Merchant’s owner(s) or officer(s),$ as appropriate. MONTHLY PRICING: $ PER MONTH SALES REP SIGNATURE: X PRINTED(INCLUDES NAME: Linnay TRANSACTIONSZazueta PER LOCATION ANNUALLYR.EP A DDITIONALID #: 23630 TRANSACTION BILLED $0.29D PERATE :TRANSACTION ) MAX CARD VALUE $ (DEFAULT $500) REP PHONE #: 4696759920 REP EMAIL: [email protected] EGC CARRIERS EGC SERVICE FEES FOR INTERNAL USE ONLY ACCEPTED BY ELAVON CANADA COMPANY: SERVICEDATE F:EES (CARDHOLDER CHARGEDELAVON ON CAN-MSP-ELV-W8ONLY-1115 UNUSED BALANCES) CARD CARRIERS (ENTER TOTAL CARDS) - CUSTOM CARDS ARE REQUIRED - FEE MERCHANT CHARGED PER TRANSACTION $0.12 # OF STYLE ADDITIONAL INFORMATION - APPLY SAME TO ALL PROVINCES? Y N (IF NO, COMPLETE FOR EACH STATE) $ X Form# W-8BEN OF SmustTYLE be signed and dated by the beneficial owner of the income, or, if the beneficialFEE owner AMOUNT is not: $ an individual, by an authorized representative or officer of the beneficial owner. Beneficial owner. For payments other than those for which a reduced rate of withholding is claimed under an income tax treaty, the beneficial owner of income is generally the person who is required under U.S. # OF STYLE APPLIED: MONTHLY QUARTERLY ANNUALLY tax principles to include the income in gross income on a tax return. A person is not a beneficial owner of income, however, to the extent that person is receiving the income as a nominee, agent, or custodian, or to (M theULTIPLES extent theOF person100 ONLY is a) conduit whose participation in a transaction is disregarded. In the caseBEGINNING of amounts: paid thatMONTHS do not AFTER constitute LAST income, TRANSACTION beneficial DATE ownership (CANNOT is BE determined LESS THAN 12 as MOS if the) payment were income. Foreign partnerships, foreign simple trusts, and foreign grantor trusts are not the beneficialLOCK owners BALANCES of income AFTER paid: to the partnership MONTHS OF or NONtrust.-USE (DEFAULT 72 MONTHS, CANNOT BE LESS THAN 60 MONTHS) PermanentEGC OPTIONS residence address. Your permanent residence address is the address in the country where you claim to be a resident for purposes EGCof that country’s NETWORK income tax. Do not show the address of a financial institution, a post office box, or an address used solely for mailing purposes. If you are an individual who does not have a tax residence in any country, your permanent residence is where you normally reside. If you are not an individual and you do not have a tax residence in any country, the permanent residence address is where you maintain your principal office. MONTHLY ONLINE ADMIN - # USERS $ MISC FEE - $ ELAVON GRAPHIC DESIGN SERVICE $ MISC FEE - $ GIVEX CUSTOM CARD UPGRADE $ EGC STANDARD CARD ORDER DETAILS

CARD STYLE: TEXT COLOR:

JUSTIFICATION: LEFT CENTER RIGHT AS SUBMITTED

LOGO (TO AVOID DELAY, PLEASE SUBMIT ARTWORK TO: [email protected] ) OR TEXT (IMPRINTING DETAILS MUST BE ENTERED BELOW) IMPRINT: FONT (SELECT ONE): Arial Brush Script Times New Roman Text Case (select ONE): Title Case UPPER CASE lower case As submitted

EGC NOTES

CURRENCY EXCHANGE

MULTI-CURRENCY OTHER VAS

MASTERCARD MASTERPASS SIGNATURE (Signature below is only required when enrolling for the Value Added Services listed on this page.)

BY SIGNING BELOW, MERCHANT WARRANTS THE TRUTHFULNESS AND ACCURACY OF THE INFORMATION PROVIDED, AGREES TO PAY THE FEES SET FORTH HEREIN.

______SIGNATURE NAME & TITLE DATE CAN-MSP-ELV-1115

______Initials 5 CAN-MSP-ELV-1115 S A L E S W O R K S H E E T TERMINAL PROGRAMMING REQUIREMENTS

TERMINAL DESCRIPTION: # OF TERMINAL IDS:

IP COMMUNICATION METHOD: (IP DEFAULT) IP DIAL

ENVIRONMENT:

QUICK CLOSE TERMINAL AUTO CLOSE TIP FUNCTION WAITER (RTL) TIP FUNCTION CASHIER (RTL) RETAIL (AUTO CLOSE DEFAULT) CASH BACK PIN DEBIT SEMI INTEGRATED

RESTAURANT (QUICK CLOSE DEFAULT) SERVER PROMPT TIP FUNCTION WAITER TIP FUNCTION CASHIER FINE DINING

CARD NOT PRESENT (AUTO CLOSE DEFAULT) QUICK CLOSE TERMINAL AUTO CLOSE

LODGING (QUICK CLOSE DEFAULT)

CUSTOM PROMPTS: INVOICE PROMPT B TO B (PROMPT ALL) TAB FUNCTION (ADDED DURING TRAINING)

PHONE INFORMATION: ACCESS #:

TRAINING INFORMATION: TRAINING CONTACT: TRAINING PHONE #:

MULTI-MID REQUEST

NEW MERCHANT RELATIONSHIP DBA: MID RANK ORDER* (1,2,3…): MULTI MID REQUEST: EXISTING MERCHANT RELATIONSHIP: EXISTING MID:

* NOTE: IF THERE IS AN EXISTING MID, THAT MID ALWAYS DEFAULTS AS THE MASTER MID (OR MID #1)

ON SITE INSPECTION

HAVE YOU PHYSICALLY BEEN ON SITE? YES NO IS MERCHANT NAME AS IT APPEARS ON SIGNAGE? YES NO

IS THE PHYSICAL SITE INSPECTED THE SAME AS THE DBA ADDRESS? YES NO IS MERCHANDISE CONSISTENT WITH TYPE OF BUSINESS? YES NO

IS THIS A RETAIL LOCATION? YES NO

BUSINESS LOCATED IN: SEPARATE BUILDING PRIVATE RESIDENCE SHOPPING CENTER/MALL OFFICE BUILDING KIOSK OTHER (DESCRIBE):

I CERTIFY THAT THE ABOVE INFORMATION IS TRUE, COMPLETE AND ACCURATE: (SIGNATURE OF REP)

PRINTED NAME: REP #: DATE:

SPECIAL INSTRUCTIONS

______Initials 6 CAN-MSP-ELV-1115