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Apply for Credit Cards Payment Processing Application Preferred Language for Communications: English French Currency: CAD USD Sales Agent: Program: Partner: Promo Code: 1 - Company Information DBA Name: Contact Name: DBA Address Type: DBA Address 1 (No PO Box) : DBA Address 2: City: Province: Postal Code: Country of Primary Business Operations: Country of Business Formation: Year Established: Length of Current Ownership: years months DBA Phone Number: DBA Fax Number: GST Number: Email Address: I agree to receive email communications from Paystone, including but not limited to product/ service announcements, marketing information Residence Location Type: Shopping Centre/Mall Office Separate Building Other and other important notices. I understand that I can unsubscribe at any time. Legal Structure: Sole Proprietor Partnership Corporation Non-Profit Government 2 - Other Address Corporate Shipping Mailing Corporate or Location Name: Address: City: Province: Postal Code: Contact: Phone: Fax: 3 - Principle Information Has the business or any of its principals been part of any claims, lawsuits, or bankruptcies, or ever been terminated or suspended by another payment processor? Yes No Principle 1 Beneficial Owner Authorized Signer Sole Proprietor Percentage of Ownership: % Title: First Name: Middle Name: Last Name: Home Address: City: State/Province: ZIP/Postal Code: Country: Phone Number: DOB: Country(ies) of Citizenship: Principle 1 Identification A copy of the piece of ID is required ID Type: ID Number: ID Type: Document Number: Issue Date: Expiry Date: Issuing Country: Issuing Province: Principle 2 Beneficial Owner Authorized Signer Percentage of Ownership: % Title: First Name: Middle Name: Last Name: Home Address: City: State/Province: ZIP/Postal Code: Country: Phone Number: DOB: Country(ies) of Citizenship: Principle 2 Identification A copy of the piece of ID is required ID Type: ID Number: Issue Date: ID Type: Document Number: Expiry Date: Issuing Country: Issuing Province: 4 - Business Verification Anti-money laundering government mandates require us to provide documentary proof of existence. Please provide a copy of the approved document, in addition to completing this section of the application. Document Type: Document Number: Issuing Country: Issuing Province: Issue Date: Expiry Date: Initials: 3200 Wonderland Road South - London, Ontario Canada N6L 1A6 - T: 1.888.900.9192 - F: 1.888.630.4539 - www.paystone.com CAN-MSPBP-ELV-0720 5 - Paystone Hub The Paystone Hub is used for reporting and monthly statement delivery. Email Address for Hub Login: 6 - Processing Information Average Sale: $ Highest Sale: $ Description of Product/Services Offered: Annual Number of High Sale Transactions: Annual Revenue: $ Total Monthly Credit Card Sales: $ Credit, debit, and cash for account being onboarded When does the customer receive the product or service? Visa Mastercard Amex (JCB) Interac If not same day, number of days (Including shipping time frame) Monthly Volume Previous Processor: No. of Transactions Reason for Leaving: If seasonal, please check months CLOSED below. (Client must contact service to deactivate and reactivate account) January February March April May June July August September October November December 7 - Card Acceptance All [Visa/Mastercard/Interac/UnionPay/Discover Cards (DI, BC CARD, Dina Card)/American Express (JCB)] Gift Card $ Program Visa Credit Visa Debit Omnicommerce Omnicommerce Must total 100% E-Gift Card Add-on: $20/month Mastercard Credit Mastercard Debit Must have Gift Card program 100% Card Present Card Present % Discover Union Pay 100% Card Not Present (DI, BC CARD, Dina Card) Card Not Present % Transfer existing gift card data Interac Debit American Express 100% Internet Internet % Multi-location merchant 8 - Pricing Information * Rates are for all card acceptance types selected. All assessment fees and interchange will be passed through at cost. Interac Debit: $ Enhanced Interchange Plus Flat Rate Interac Flash: +$0.035 Visa Mastercard Amex (JCB) Discover UnionPay Merchant Surcharge: $ x 33% Qualified % % % % % Application Fee: $ Non-Qualified % % % % N/A Setup Fee: $ Authorization Fee: $ PCI Security Other fees may apply Membership Fee: $ Settlement: $ Standard: $ Existing Amex Number: Monthly Fee: $ PCI Plus: $ Contactless Transactions (including Apple Pay and Google Pay) are enabled by default. Contactless Amex per transaction: $ Monthly Minimum: $ safe-t: $ specific fees aply for Interac only. Uncheck this box *Required with Poynt to opt out of accepting contactless transactions 9 - Bank Account Deposit Account Bank Name: Transit No.: Institution No.: Account No: Billing and Chargebacks Check if same as deposit account Bank Name: Transit No.: Institution No.: Account No: Initials: 3200 Wonderland Road South - London, Ontario Canada N6L 1A6 - T: 1.888.900.9192 - F: 1.888.630.4539 - www.paystone.com CAN-MSPBP-ELV-0720 10 - Software and Equipment Add-ons 10A - Terminals Ingenico Desk/5000 Ingenico Move/5000 Desk/5000e Rent Purchase Wi-Fi Rent Purchase $ each Quantity: (Ethernet only) Bluetooth with $ each Quantity: Rent Purchase $ each Quantity: COMM Base 4G Cellular Rent Purchase $ each Quantity: Rent Purchase Desk/1500 * Additional wireless fee: $15/month, Pin Pad per terminal, per SIM Comments: $ each Quantity: Telus Bell Rogers 10B - Poynt Smart Terminals Poynt Smart Terminal Poynt 5 Smart Terminal Dynamic Currency Conversion (DCC) Poynt V2 Rent Purchase Poynt 5 Rent Purchase DCC Conversion Rate: 3.75% DCC Rebate Rate: 1.55% $ each Quantity: $ each Quantity: DCC Exchange Rate Source: US Bank Poynt 3G Rent Purchase Poynt 5 - 3G Rent Purchase * Additional $15/month, per terminal for 3G $ each Quantity: $ each Quantity: * Poynt HQ included * Additional $15/month, per temrinal for 3G * Poynt HQ included Poynt Peripherals Smart Bundle: Cash Drawer (Epson 1616 - CAN) Printer (Epson M30 - CAN) Advanced Dock Power Sleeve Cash Drawer + Compact Printer Rent Purchase Rent Purchase Rent Purchase Purchase Purchase $ each $ each $ each $ each $ each Quantity: Quantity: Quantity: Quantity: Quantity: 10C - Integrated Solutions Point of Sale (POS) POS System: Version: Semi-Integrated talech Rent Purchase Secure Rent Purchase Annual Site License Table Pay + Desk/5000 Other $ each Quantity: Move/5000 $ each Quantity: $ Move/5000 talech Rent Purchase Quantity: Bluetooth with Other $ each Quantity: Wi-Fi 4G Cellular COMM Base Setup Fee: $ Bluetooth with Telus Bell Rogers Telus Bell Rogers Wi-Fi 4G Cellular COMM Base * Additional wireless fee: $15/month, * Additional wireless fee $15/month, per terminal, per SIM per terminal, per SIM 10D - Gateways Options: Fees: Converge Virtual Terminal must Converge be selected. Virtual Terminal Tokenization Setup Fee: $ Link/2500 Bambora Mobile E-commerce Website: Monthly Fee: $ $25 billed by Paystone (Swiper sold seperately) iPP320 Rent Purchase Authorize.Net Converge Billing & Invoicing Automatic Card Updater $25 billed by Auth.net Add $20 (prerequisite Add $20 (setup fee: $450 + $0.25 tokenization & e-commerce) per match) $ each Quantity: 10E - talech talech talech Elo Includes: Elo Pay Station (cash register, barcode scanner, iPad stand Standard License Quantity: Premium License Quantity: & printer). iPAD not included. Note: Order integrated Desk/5000 and Package Move/5000 in section 10 C - Integrated Solutions. $69.95/month for the first device $89.95/month for the first device $39.95/month for each additional device $49.95/month for each additional device (Separate lease Quantity: $ each agreement required) Purchase Quantity: $ each Online Ordering Quantity: Custom talech Order (Separate order form required) $49.95/month Initials: 3200 Wonderland Road South - London, Ontario Canada N6L 1A6 - T: 1.888.900.9192 - F: 1.888.630.4539 - www.paystone.com CAN-MSPBP-ELV-0720 11 - Purchase Information Total Purchase Amount: $ 1. Using your Bank Account 2. Using your Credit Card Email Address: Required The total purchase amount A purchase invoice including all purchased equipment will be emailed to the email address will be billed on the first day of above. Follow the instructions to complete a credit card payment. If this invoice is not paid the upcoming month on your within 1 week of issuance, the Total Purchase Amount will be added to your monthly bill or merchant statement. withdrawn via PAD from your account. 12 - Terms, Conditions, and Pre-Authorized Debit By signing below, you agree to be bound by the terms and conditions of this Application and the related Terms and Conditions found online at https://www.Paystone.com/legal/pay-terms-and- conditions, and http://Paystone.com/legal/hub-terms-of-service and Paystone’s Privacy Policy found online at http://www.Paystone.com/privacypolicy (collectively, the “Terms and Conditions”). Capitalized terms not defined herein will have the meaning ascribed to them in the Terms and Conditions. In the event of a conflict between the Terms and Conditions of this Pay Application and the Terms and Conditions, the Terms and Conditions shall govern. Pre-Authorized Debit (PAD) This PAD is for: Personal Use Business Use By signing this Pre-Authorized Debit (PAD) Agreement, you authorize Paystone Inc. (“Paystone”) and your bank or credit card company to periodically debit or charge the account identified in this Payment Processing Application (the “Application”) the full monthly amount incurred by you from time to time in respect of any recurring monthly fees and/or charges for services provided by Paystone or its affiliates or service providers, both fixed and variable,
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