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 credit card.
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, American Express, ______Discover Card, JCB, EnRoute, Diners Club, Solo/Maestro
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: ______