INSTRUCTIONS

Complete and return by fax to 904.437.4050 or via email to [email protected]. U.S. and Canadian merchants must return a copy of a VOIDED Check. International Merchants (e.g. Non U.S. and Canadian) must complete and return our payment authorization form, listing a billable .

The merchant’s checking account or credit card will be billed the monthly gateway fee.

Rates & Pricing (All Prices in US Dollars. Prices Subject to Planetauthorize™ Payment Gateway Setup Form Change without Notice) (for merchants who already have a merchant account)

Complete and return by fax to 904.437.4050 or via email to [email protected]. Gateway/Virtual Terminal Attach a company VOIDED Check. Be sure to complete the Merchant Account Configuration information section. -One-Time Set-up: $ 79.00 (waived with merchant account) Company Information -Monthly Gateway Fee: $ 20.00 -Transaction Fee: FREE Date: ______($0.05 cents After first 250 monthly transactions)

Company Name: Electronic Checks ______-Setup Fee: $95.00 Address: -Monthly Service Fee: $15 ______-Discount Rate: 0.0% (no charge) City, State/Province, Zip Code: - Transaction Fee: $ .50 cents ______Recurring Billing Phone: ( ______) ______- Free (included as a standard feature) Fax: (______) ______iSpy Fraud™/FraudSensor™ Email: - No Setup Fee ______-Monthly Gateway Fee: $ 10.00 -Transaction Fee: $ .10 cents Website Address: ______Customer Vault™ - No Setup Fee Business Type (select one) : -Monthly Gateway Fee: $ 10.00 ___ Corporation ___ Limited Liability Company ___ Sole Proprietor -Transaction Fee: $ .10 cents ___ Partnership ___ Non-Profit ___ Trust Payment Software/Modules Date Established: Mo ______Year ______- Openbravo POS: Free

- WHMCS: Free Description of Products/Services Sold: - Plesk Billing: Free ______- AWBS Billing: Free

- SugarCRM: $99.00 Company Tax (EIN) or Social Security #:______- vtiger CRM: $99.00 Company Contact: - MobileAuthorize: Free ______- Certified Shopping Carts: Free

Accepted Cards IT/Technical Contact: Visa, MasterCard, , ______Discover Card, JCB, EnRoute, Diners Club, /

Processing Method: ____ eCommerce ____ MOTO _____ Retail _____ Restaurant ____ Mobile

Requested Add-On Services:

______Electronic Checks _____Customer Vault™ _____ iSpy Fraud™ _____RetailPayments VPOS SwIPe ______Electronic Invoicing _____SyncPay™ for QuickBooks® _____CertifyPCI™ ______MobileAuthorize™ (iPhone, Google Android, Windows Phone/Surface, BlackBerry) ______SugarCRM Payment Module _____vtiger CRM Payment Module ______Salesforce Payment Module ______WHMCS _____ Plesk Billing _____ AWBS Billing ______Openbravo POS _____ Payer Authentication _____ Data Decryption _____ Other

Corporate Officer/Owner/Principal Information

Name (First, MI, Last) ______

Title: ______Date of Birth______

Phone: ______Email: ______

Merchant Account Processor Configuration Information

Please provide the account information for ONE Processor that is associated with your Merchant Account. If you have any questions regarding which Processor Network your Merchant Account uses, please contact your Merchant Services Provider.

First Data Corporation (FDC)- Nashville Platform

Merchant Account Bank or Acquirer Name: ______

Merchant ID (MID): ______(7-11 digits)

Terminal ID (TID): ______(7-11 digits)

First Data Corporation (FDCO)- Omaha Platform

Merchant Account Bank or Acquirer Name:______

Merchant ID (MID): ______(15-16 digits)

ELAVON - Platform

Merchant Account Bank or Acquirer Name:______

Bank BIN/Terminal BIN#: ______(6 digits)

Terminal ID (TID): ______(16 digits)

TSYS/Vital (VisaNet) Merchant Account Bank Acquirer Name: ______

Acquirer BIN: ______(6 Digits)

Category Code: ______(4 digits)

Agent Bank Number: ______(6 Digits)

Merchant Number ______(12 digits)

Agent Chain Number: ______(6 Digits)

Store Number ______( 4 digits)

Terminal Number (TID): ______(4digits)

Location Number: ______(5 digits)

Vital Number: ______(8 digits)

Global Merchant Account Bank or Acquirer Name: ______

Acquirer Institution ID (Bank ID)#: ______

Merchant ID (MID): ______

Paymentech (Tampa and Salem supported) Merchant Account Bank or Acquirer Name: ______

Client Number ______(4-Digits)

Merchant # (Gensar #): ______(12 digits)

Terminal Number (TID) ______(3 digits)

PNS Number: ______

VoicePay/Voice Commerce

Auth ID: ______

Auth Password: ______

Currency: ______

COMPLETE AND RETURN BY FAX 904-437-4050 OR EMAIL [email protected]

Credit Card Payment Authorization Form

I (We) hereby authorize SaleManager or its authorized affiliates, to initiate credit card credit and/or debit entries, if necessary, adjusting entries made in error to the account indicated below:

Name on Credit Card:

______

Billing Address

______

City: ______State/Province: ______Zipcode: ______

Credit card Number: ______

Type (check one): [ ] American Express, [ ] MasterCard, [ ] Visa, [ ] Discover

Expiration Date: ______CVV Number: ______

This authorization shall remain in effect until SaleManager receives written notification of its termination.

Name of Authorized Signer (Print name): ______

Title: ______

Company Name: ______

Telephone: ______Fax: ______

Email: ______

Signature: ______Date: ______

Electronic Check/ACH Payment Authorization (US & Canadian Merchant)

I (We) hereby authorize SaleManager or its authorized affiliates, to initiate ACH credits and/or debit entries, if necessary, adjusting entries made in error to the account indicated below. I also agree to pay a $25 bounce check fee if my check is returned for any reason:

Name on Business Checking Account:

______

Billing Address

______

City: ______State/Province: ______Zipcode: ______

Checking Account Number: ______

Routing Number: ______

**** RETURN A COPY OF A VOIDED CHECK WITH THIS PAYMENT FORM *******

This authorization shall remain in effect until SaleManager receives written notification of its termination.

Name of Authorized Signer (Print name): ______

Title: ______

Company Name: ______

Telephone: ______Fax: ______

Email: ______

Signature: ______Date: ______