Merchant Application Form

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EPI 1306

PAGE 1 OF 3

EPI 1306

Merchant Application

OFFICE
USE
ONLY		 Merchant# ISO Office Name

Synapse Payments
SIC/MCC Code FICO Score Analyst ISO Office Phone

800-925-5191

 ISO Office Code

PTS70
ISO USE
ONLY 		Option A
1 | MERCHANT INFORMATION
Merchant Business Name (Doing Business As)
Merchant Legal/Corporate Name (if Different From DBA)
DBA Outlet Address
Legal Address
DBA Outlet City, State & ZIP code
Legal City, State & ZIP code
Contact Name
DBA Location Telephone
Customer Service Telephone #
Website Address (if applicable)
Merchant Email Address (REQUIRED)
2 | IRS DISCLOSURE AND FORM W-9

NOTE: Failure to provide accurate information may result in a withholding of merchant funding per IRS regulations (see section 33.3 of your program guide for further information).
IRS Name
(Exactly as it appears on your Income Tax Returm) 		Federal Tax ID #
(Used to file your Income Tax Return)
TIN Type

MUST Check One Box

3 | OWNERS/OFFICERS/PARTNERS
Owner/Principal #1 (PRINT) Equity Ownership
%
Social Security # Telephone #
Residence Address
City, State & ZIP Code Date of Birth
Driver’s License # State of Issuance
Has owner/principal disclosed above filed bankruptcy or been subject to an involuntary bankruptcy?

4 | OWNERS/OFFICERS/PARTNERS
Owner/Principal #1 (PRINT) Equity Ownership
%
Social Security # Telephone #
Residence Address
City, State & ZIP Code Date of Birth
Driver’s License # State of Issuance
Has owner/principal disclosed above filed bankruptcy or been subject to an involuntary bankruptcy?

7800 Congress Avenue, Suite 112 Phone: 800-966-5520 | Fax: 866-780-7587

Boca Raton, Florida 33487 www.electronicpayments.com

Electronic Payments is a registered Independent Sales Organization of Wells Fargo Bank, N.A., Concord, CA

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EPI 1306

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EPI 1306

5 | MERCHANT PROFILE AND PROCESSING SUMMARY
What is your annual gross business volume?
$
What is your annual credit card volume?
$
What is your average charge amount?
$
What is the highest charge you will need to process?
$
WHERE IS THE SALE TRANSACTED?
Merchant Location % Merchant Website % Mail/Telephone Order % Mobile Device %
HOW IS THE TRANSACTION COMPLETED?
Card/Chip Read % Manual Entry % Voice Authorization % Online Gateway%
When are your credit card sales deposited?
Date of Order Date of Delivery Other (please explain)
What is your refund policy? Explain if necessary:
No Refunds Exchange Only Full Refund Store Credit
What is the time frame for delivery of the product?
0-7 Days 8-15 Days 16-30 Days 30+ Days
Business Start Date
Are customers required to leave deposits?
Yes No If Yes, percentage required: %
Do you perform recurring transactions or auto-renewals? (Please explain)
Yes No
6 | MERCHANT SITE SURVEY AND SUMMARY
Merchant location has been physically inspected by agent
Yes No
Merchant lead was generated via the internet
Yes No
Give a detailed explanation of the merchandise and/or services sold/performed by the merchant: Business Type
Retail Restaurant Lodging Petroleum
Tradeshow Car Rental Internet MO/TO
Business Location Type
0-7 Days Office Building Home - Based Restaurant Mixed Use Other
Does the merchant inventory and merchandise on shelves and floor appear consistent with the type of business specified above? (If no, please explain)
Yes No
Square footage
0-250 251-500 501-2,000 2,000+
I hereby verify that this application has been fully completed by the merchant and that the business premises of the merchant at this address and the information stated above is true and correct to the best of my knowledge and belief. Any misrepresentation may result in losses and/or liabilities. EPI may contract with a third party to schedule an external site survey and I or the merchant will schedule an appointment immediately upon request.
7 | EXISTING ENTITLEMENTS
Have you previous had an American Express SE #?
Yes No
8 |BANKING INFORMATION
Transit ABA Routing Number
DDA Account Number
9 | SERVICE FEE SCHEDULE
Visa Credit Visa Debit Discover® Network MasterCard Credit MasterCard Debit
American Express OptBlue® PIN Debit/ATM Electronic Benefits (EBT) Wright Express Voyager
SERVICE FEE SCHEDULE: American Express OptBlue®
OptBlue® Simplified Merchant Pricing
Simplified Merchant Pricing is based upon MCC code and varies between 2.65% to 3.6% for Qualified with additional surcharges and fees listed below, in the Program Guide and in your Welcome Kit.
OptBlue® Discount Rate plus Passthrough Interchange, Dues, Assessments, Fees and EPI Surcharges
American Express OptBlue® % + $ Per Item
Prepaid Gift Card Charges and Fees: % + $ Per Item
Select Grid 7 - IC Plus* 22 - RCD 23 - Surcharge Other
Additional Fees Include:
An Inbound fee of 1% will be applied by American Express® to any Charge made by an American Express Cardmember using a Card issued by an American Express Issuer located outside of the United States.
0.30% downgrade will be charged by American Express® for transactions whenever a CNP or Card Not Present Charge occurs. CNP means a Charge for which the Card is not presented at the point of purchase (e.g., Charges by mail, telephone, fax or the Internet).
*0.30% to 1% processor settlement fee will be charged by Electronic Payments on any transactions processed and settled by Electronic Payments.
*0.165% Network Fee will be charged by American Express® on all sales.

Electronic Payments is a registered Independent Sales Organization of Wells Fargo Bank, N.A., Concord, CA

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EPI 1306

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EPI 1306

5 | MERCHANT PROFILE AND PROCESSING SUMMARY
What is your annual gross business volume? $ What is your annual credit card volume?
$
What is your average charge amount?
$
What is the highest charge you will need to process?
$
WHERE IS THE SALE TRANSACTED?
Merchant Location % Merchant Website % Mail/Telephone Order % Mobile Device %
HOW IS THE TRANSACTION COMPLETED?
Card/Chip Read % Manual Entry % Voice Authorization % Online Gateway%
When are your credit card sales deposited?
Date of Order Date of Delivery Other (please explain)
What is your refund policy? Explain if necessary:
No Refunds Exchange Only Full Refund Store Credit
What is the time frame for delivery of the product?
0-7 Days 8-15 Days 16-30 Days 30+ Days
Business Start Date
Are customers required to leave deposits?
Yes No If Yes, percentage required: %
Do you perform recurring transactions or auto-renewals? (Please explain)
Yes No
6 | MERCHANT SITE SURVEY AND SUMMARY
Merchant location has been physically inspected by agent
Yes No
Merchant lead was generated via the internet
Yes No
Give a detailed explanation of the merchandise and/or services sold/performed by the merchant: Business Type
Retail Restaurant Lodging Petroleum
Tradeshow Car Rental Internet MO/TO
Business Location Type
0-7 Days Office Building Home - Based Restaurant Mixed Use Other
Does the merchant inventory and merchandise on shelves and floor appear consistent with the type of business specified above? (If no, please explain)
Yes No
Square footage
0-250 251-500 501-2,000 2,000+
I hereby verify that this application has been fully completed by the merchant and that the business premises of the merchant at this address and the information stated above is true and correct to the best of my knowledge and belief. Any misrepresentation may result in losses and/or liabilities. EPI may contract with a third party to schedule an external site survey and I or the merchant will schedule an appointment immediately upon request.
7 | EXISTING ENTITLEMENTS
Have you previous had an American Express SE #?
Yes No
8 |BANKING INFORMATION
Transit ABA Routing Number
DDA Account Number
9 | SERVICE FEE SCHEDULE
Visa Credit Visa Debit Discover® Network MasterCard Credit MasterCard Debit
American Express OptBlue® PIN Debit/ATM Electronic Benefits (EBT) Wright Express Voyager
SERVICE FEE SCHEDULE: American Express OptBlue®
OptBlue® Simplified Merchant Pricing
Simplified Merchant Pricing is based upon MCC code and varies between 2.65% to 3.6% for Qualified with additional surcharges and fees listed below, in the Program Guide and in your Welcome Kit.
OptBlue® Discount Rate plus Passthrough Interchange, Dues, Assessments, Fees and EPI Surcharges
American Express OptBlue® % + $ Per Item
Prepaid Gift Card Charges and Fees: % + $ Per Item
Select Grid 7 - IC Plus* 22 - RCD 23 - Surcharge Other
Additional Fees Include:
An Inbound fee of 1% will be applied by American Express® to any Charge made by an American Express Cardmember using a Card issued by an American Express Issuer located outside of the United States.
0.30% downgrade will be charged by American Express® for transactions whenever a CNP or Card Not Present Charge occurs. CNP means a Charge for which the Card is not presented at the point of purchase (e.g., Charges by mail, telephone, fax or the Internet).
*0.30% to 1% processor settlement fee will be charged by Electronic Payments on any transactions processed and settled by Electronic Payments.
*0.165% Network Fee will be charged by American Express® on all sales.

Electronic Payments is a registered Independent Sales Organization of Wells Fargo Bank, N.A., Concord, CA

Beneficial Ownership

EPI 1306

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EPI 1306

Beneficial Ownership
Addendum

Provide the following information for each individual who owns, directly or indirectly, 25% or more of the equity interest of your business.

OWNERS/OFFICERS/PARTNERS

Owner/Principal #3 (PRINT)

Equity Ownership

%

Social Security #

Telephone #

Residence Address

City, State & ZIP Code

Date of Birth

Driver’s License #

State of Issuance

Has owner/principal disclosed above filed bankruptcy or been subject to an involuntary bankruptcy?

OWNERS/OFFICERS/PARTNERS

Owner/Principal #4 (PRINT)

Equity Ownership

%

Social Security #

Telephone #

Residence Address

City, State & ZIP Code

Date of Birth

Driver’s License #

State of Issuance

Has owner/principal disclosed above filed bankruptcy or been subject to an involuntary bankruptcy?

OWNERS/OFFICERS/PARTNERS

Owner/Principal #5 (PRINT)

Equity Ownership

%

Social Security #

Telephone #

Residence Address

City, State & ZIP Code

Date of Birth

Driver’s License #

State of Issuance

Has owner/principal disclosed above filed bankruptcy or been subject to an involuntary bankruptcy?

OWNERS/OFFICERS/PARTNERS

Owner/Principal #6 (PRINT)

Equity Ownership

%

Social Security #

Telephone #

Residence Address

City, State & ZIP Code

Date of Birth

Driver’s License #

State of Issuance

Has owner/principal disclosed above filed bankruptcy or been subject to an involuntary bankruptcy?

7800 Congress Avenue, Suite 112
Boca Raton, Florida 33487

7800 Congress Avenue, Suite 112
Boca Raton, Florida 33487

Electronic Payments is a registered Independent Sales Organization of Wells Fargo Bank, N.A., Concord, CA

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EPI1306

CONFIRMATION PAGE

Please read the Program Guide in its entirety. It describes the terms under which we will provide merchant processing services to you.

From time to time you may have questions regarding the contents of your Agreement with Bank and/or Processor. The following information summarizes portions of your Agreement in order to assist you in answering some of the questions we are most commonly asked.

  1. Your discount rates are assessed on transactions that qualify for cer-tain reduced interchange rates imposed by MasterCard, Visa and Discover Network. Any transactions that fail to qualify for these reduced rates will be charged an additional fee (see Section 17 of the Program Guide).

  2. We may debit your bank account from time to time for amounts owed to us under the Agreement

  3. There are many reasons why a Chargeback may occur. When they occur we will debit your settlement funds or settlement account. For a more detailed discussion regarding Chargebacks, see Section 10.

  4. If you dispute any charge or funding, you must notify us within 60 days of the date of the statement where the charge or funding appears or should have appeared.

  5. The Agreement limits our liability to you. For a detailed description of the limitation of liability see Section 19.

  1. We have assumed certain risks by agreeing to provide you with Card processing. Accordingly, we may take certain actions to mitigate our risk, including termination of the Agreement, and/or hold monies otherwise payable to you (see Section 22, Term; Events of Default and Section 23, Reserve Account; Security Interest).

  2. By executing this Agreement with us you are authorizing us and our Affiliate to obtain financial and credit information regarding your business and the signer and guarantors of the Agreement until all your obligations to us and our Affiliate are satisfied.

  3. The Agreement contains a provision T that in the event you terminate the Agreement early, you may be responsible for the payment of early termination fees as set forth in Section 33, Additional Fee Information.

  1. Card Organization Disclosure

    Visa and MasterCard Member Bank Information: Wells Fargo Bank, N.A.

    The Bank’s mailing address is P.O. Box 6079 Concord, CA 94524, and its phone number is 1 844-284-6834

Important Member Bank Responsibilities:

  1. The Bank is the only entity approved to extend acceptance of Visa and MasterCard products directly to a Merchant.

  2. The Bank must be a principal (signer) to the Merchant Agreement.

  3. The Bank is responsible for educating Merchants on pertinent Visa and MasterCard rules with which Merchants must comply; but this information may be provided to you by Processor.

  4. The Bank is responsible for and must provide settlement funds to the Merchant.

  5. The Bank is responsible for all funds held in reserve that are derived from settlement.

Important Merchant Responsibilities:

  1. Ensure compliance with cardholder data security and storage requirements.

  2. Maintain fraud and chargebacks below Card Organization thresholds.

  3. Review and understand the terms of the Merchant Agreement.

  4. Comply with Card Organization rules.

By its signature below, Client acknowledges that it received the complete Program Guide [Version EPll306 ] consisting of 26 pages (including this confirmation).

Client further acknowledges reading and agreeing to all terms in the Program Guide, which shall be incorporated into Client’s Agreement.

Upon receipt of a signed facsimile or original of this Confirmation Page by us, Client’s Application will be processed.

Client understands that a copy of the Program Guide is also available for downloading from the Internet at:

NO ALTERATIONS OR STRIKE-OUTS TO THE PROGRAM GUIDE WILL BE ACCEPTED AND, IF MADE, ANY SUCH ALTERATIONS OR STRIKE-OUTS SHALL NOT APPLY.

Client’s Business Principal:

Signature (Please sign below):

TitleDate Please Print Name of Signer

EPI1306

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Electronic Payments is a registered Independent Sales Organization of Wells Fargo Bank, N.A., Concord, CA