MERCHANT BANK CARD APPLICATION AND AGREEMENT
1. BUSINESS INFORMATION
Customer's Business Name (Doing Business As)
 Customer's Corporate Name (Use Also For Headquarter's Information)
Business Address
 Billing Address (If Different Than Location Address)
City, State, Zip
 City, State, Zip
Location Phone #
 Location Fax #
Contact Name
Business e-mail or Website Address
Contact Phone #
 Contact Fax # / e-mail Address
We Give Our Permission To Release
Our Customer Service Phone # 		Send Monthly Merchant Statements To:
Corporate Headquarters Business Location
2. TYPE OF BUSINESS
Corporation -
State of Inforporation: 		LLC -
County And State In Which Certificate Of Assumed Name Filed:
Partnership -
County And State In Which Certificate Of Assumed Name Filed: 		Sole Proprietorship -
County And State In Which Certificate Of Assumed Name Filed:
Federal Tax ID #
Detailled Explination of Type of Merchandice, Products Or Services Sold
3. COMPANY HISTORY
Date Business Started
MM/DD/YY 		Length of current ownership
Prior Bankruptcies?
No Yes
Business and / Or Personal 		Date Discharged
4. OWNERS / PARTNERS / OFFICERS
OWNER / PARTNER / OFFICER 1
 OWNER / PARTNER / OFFICER 2
 OWNER / PARTNER / OFFICER 3
Name
 Name
 Name
Title
 Title
 Title
Home Address
 Home Address
 Home Address
City, State, Zip
 City, State, Zip
 City, State, Zip
Social Security #
 Social Security #
 Social Security #
Telephone #
 Telephone #
 Telephone #
5. REFERENCES
BANK REFERENCE
 TRADE REFERENCE
 LANDLORD / MORTGAGE HOLDER
Name
 Name
 Name
Address
 Address
 Address
City, State, Zip City, State, Zip City, State, Zip
Contact
 Contact
 Contact
Telephone #
 Telephone #
 Telephone #
Account #
 Account #
 Rent / Mortgage Payment Amount
6. CURRENT /PRIOR PROCESSOR
Current / Prior Bankcard Processor's Name
 City, State, Zip
Merchant Number
 Termination Reason
7. SETTLEMENT INFORMATION
Depository Bank
 Branch
 City, State, Zip
Transit / ABA #
 Deposit Account #
8. TRANSACTION INFORMATION
FINANCIAL DATA WHERE IS SALE TRANSACTED? HOW IS TRANSACTION COMPLETED?
Gross Annual Sales Volume
$
Store Front
% 		Mail Order
%
Manual Entry With Imprint
%
Average Monthly Bankcard Volume
$
Flea Market
% 		Wholesale
%
Manual Entry Card Not Present Or Imprinted
%
Average Bankcard Ticket (Estimate IfNever Process in Past)
$
Door To Door
% 		Telephone
%
Electronic Data Capture
%
Seasonal?
No Yes 		High Volume Months
Internet
% 		Other (specify)
%
Other
%
9. EQUIPMENT INVENTORY - EXISTING OR PURCHASING
Purchasing Price Does Not Include Sales Tax Or Shipping And Handling Charges.
Wireless Vendor: Wireless Network:
Application Type:
Retail Restaurant W/Tip Quick Serve Restaurant W/Tip Hotel Retail Lodging Retail W/Tip
TRML Model Quantity Purchase Rent/Lease Existing* Total Cost $
PC Software Quantity Purchase Rent/Lease Existing* Total Cost $
Printer Model Quantity Purchase Rent/Lease Existing* Total Cost $
PIN Pad Quantity Purchase Rent/Lease Existing* Total Cost $
**Manual Imprinter Quantity Purchase Existing Plate Size x Total Cost $
(** Note: Imprint Must Be Obtained When Transaction Is Keyed)         (*Reprogramming Fee For Existing Equipment)
10. SHIP EQUIPMENT TO:
Merchant Location Agent Bank Sales Office Other (Name):
Address: City, State, Zip Attention:
11. SCHEDULE OF FEES:
Master Card % Application Fee $ (per location) Minimum Monthly Fee $ AVS Fee $
Visa % Statement Fee $ Misc. Transaction Fee $
MC/Visa Auth. & Capture Fee $ Debt Access Fee $ Wireless Fee $ Debit Transaction Fee $
Other Fees Chargeback Fee $
Description $ E-Merchant View $ Voice Authorization $
Description $
SURCHARGE OF % APPLIED TO ALL TRANSACTIONS WHICH FAIL TO MEET VISA AND MASTERCARD REQUIREMENTS FOR ELECTRONIC DATA CAPTURE INTERCHANGE REQUIREMENTS.
*Optional Mid-Qualification Rate of % applied for 3 Tiered Pricing Only
12. OPTIONAL SERVICES:
Other Card Services Merchant Number Per Transaction Cost  
American Express Access Code
(If Required For Outside Line)
Diner's / Carte Blanc
Discover
Check Guarentee/Verification (specify)
 Assigned Chain Code
Other Card Type (specify)
13. SIGNATURE(S)

On benalf of customer, the undersigned certifies that all information set fourth in this completedMerchant Bank Card Application and Agreement is true and correct and that it has received a copy of the Terms and Conditions, which are part of this Merchant Bank Card Application and Agreement and by this reference expressly incorporated herin. The undersigned merchant authorizes First Data Merchant Service Corporations ("FDMS") and The Northern Trust Company ("Bank") and their agents to investigate the references, statements and other data contained herin and to obtain additional information from credit bureaus and other lawfull sources, including persons and companies named in this Merchant Bank Card Application and Agreement. The undersigned individual authorizes FDMS and Bank and their agents (a) to procure information from any consumer reporting agency bearing his/her personal credit worthiness, credit standing, credit capacity, characater, general reputation, personal characateristics, or mode of living, and (b) to contact all previous employers, personal references and education institutions.

On behalf of customer, the undersigned agrees to all the terms of this Merchant Bank Card Application and Agreement. This Merchant Bank Card Application and Agreement shall not take effect until customer has been approved and this Agreement has been accepted by FDMS and Bank.

Merchant Owner / Officer Signature X ______________________ Title _______________________ Date _____________

Personal Guarantee
The undersigned guarantees to FDMS and Bank the perfomance of this Agreement and any addendum thereto by Customer, including payment of all sums due and owing and any attorney fees and costs associated with enforcements fo the terms thereof. FDMS and Bank shall not be required to first proceed against Customer or enforce any other remedy before proceeding against the undersigned individual. This is continuing guarantee and shall not be discharged or affected by the death of the undersigned and shall bind the heirs, administrators, representatives and assigns and be enforced by or for the benefit of any successor of FDMS and Bank. The term of this guarantee shall be for the duration of the Merchant Processing Agreement and any addendum thereto and shall guarantee all obligations which may arise or occur in connection with my activities during the term thereof through enforcement shall be sought subsequent to any termination.

Witness X _____________________ Date _____________ Personal Guarantee Signature X _____________________ Date _____________
ACCEPTED BY

Signature X __________________________________________ Title _______________________ Date _____________