client activation template · client activation template sic date legal name address zodoc acct...

Client Activation Template

SIC

DATE

LEGAL NAME

ADDRESS ZODOC ACCT STATUS

CITY LEVEL TIER 4 SALES ORG

COUNTY STATUS ACTIVE

STATE SYSTEM MORE THAN 10 YEARS

ZIP CODE CHGBK % < 1%DBA NAME

LOCATOR BB&TADDRESS

BIN SPNSR WELLS FARGOCITY

RISK MNGR V.VASSERMANCOUNTY

STATEAPPS MNGR TF

ZIP CODEVERIFIED BY VV

DBA PHONE SR. ANALYST

CONTACT CLOVER EMAIL

CONTACT PHONE

EMAIL

FAX

WEB SITE

FEDERAL TAX ID

MERCHANDISE SOLD

BUSINESS START DATE

YEARS IN BUSINESS

YEARS THIS OWNER

# LOCATIONS Merchant Number

PREV PROCESSOR|MID

YEARLY V|MC VOLUME 1,080,000.00 ✔ CORPORATION

MONTHLY REVENUE ✔ CORPORATION S

HIGHEST TICKETPROPRIETORSHIP

AVERAGE TICKET 450.00PARTNERSHIP

OWNER LLC

TITLETAX EXEMPT

HOME ADDRESSFOREIGN ENTITY

CITYMEDICAL OR LEGAL

OPT BLUE ✔

STATEASSO|ESTATE|TRUST

ONE POINT N/A

ZIP CODEGOVERNMENT

MONTHLY AMEX 0.00

PHONE Current Amex #

SOCIAL SECURITY #RETAIL CARD SWIPED WIFI WPA

DOBRESTAURANT KEYED WIRELESS

PERSONAL EMAILLODGING MOTO DIAL

DRIVERS LICENSE✔ MOTO INTERNET VoIP OK

TOLL FREE PHONE #'s E-COMMERCE Empoyees # AUTO BATCH

TOLL FREE FAX #'s HOME BASED Registers # TIME 6:45 PM

OTHER PHONE #'s

OTHER PHONE #'s BUISNESS 2 BUISNESS

BANK ATM

PHONE ERP SOFTWARE Exisiting

ROUTING INTERNET GATEWAY

ACCOUNT # FIBERCALL $ 0.00

IMPLIMENTATION NOTESCommerce Solution

UCaaS

Web Design | Build | Mgmt

WMS

UCaaS

ASSUMPTIONS Status is the Higher LevelASSUMPTIONS BASED ON ACTUAL NUMBERS FROM CURRENT STATEMENTS

AmEx Volume / Excluded

TOTAL VOLUME $ 90,000.00

ITEMS 200

TOTAL FEES $ 3,100.00

V/MC/DISC VOLUME $ 90,000.00 % DEBIT 27%

AMEX VOLUME $ 0.00 AVERAGE TICKET $ 450.00

* DEBIT VOLUME $ 24,000.00 CLIENT REWARDS $ 299.00R RE QSR

CURRENT RETAILChoose Model (Mini Only) Clover Mini WiFi or 3G INCL

Clover Mobile WiFi/3G Clover Mobile INCL

Clover Station POS Clover Station INCL

TOTAL VOLUME $ 90,000.00Clover Flex Clover Flex INCL

Clover Go BT Clover Go Bluetooth INCL

BUNDLED RATE 3.44%

Clover Mobile Dock Clover Mobile Dock INCL

Clover Mobile Printer Clover Mobile Printer INCL

Clover Cash Drawer Clover Cash Drawer INCL

TOTAL FEES $ 3,100.00Clover Flex Kit Clover Flex Kit INCL

Clover Go Stand Clover Go Stand INCL

TIER 1 TAP

Choose or Add INCL

Choose or Add INCL

WHOLESALE RATE 0.10% Tier 1 Enterprise Services 1 $ 772.10 ITEMS $ 0.06

TOTAL VOLUME $ 90,000.00ENTERPRISE RATE CLASS TRANS ARMOR 0.00 # UNITS 1 $ 772.10 TSR

0 60 FILE $ 12.00

BUNDLED RATE 2.04% Thinking Small

TOTAL FEES $ 2,092.17 CREDIT ITEMS DEBIT ITEMS MISC ITEMS

STEP UP TO ENTERPRISE$ 66,000.00 147 $ 24,000.00 53 $ 12.00 ON FILE

1.87% $ 0.16 0.15% $ 0.27 $ 772.10 TSR

RETAIL FEES $ 3,100.00$ 1,234.20 $ 23.47 $ 36.00 $ 14.40 $ 784.10 $ 2,092.17

UCaaS Equipment

TIER ONE FEES $ 2,092.17ULTRA ELEGANT PREMIUM Ultra Elegant Touch Screen Gigabit IP Phone

ULTRA ELEGANT STANDARD GIGABIT Ultra Elegant Gigabit IP Phone

MONTHLY SAVINGS $ 1,007.83BUSINESS HD-DECT CORDLESS PHONEBusiness HD DECT Cordless Phone

LT1250CONFROOM Deluxe LT1250CONFROOM Deluxe

ANNUAL SAVINGS $ 14,435.44

Add/Choose Add-Ons Edgemark 2900E

Add/Choose Add-Ons

Add/Choose Add-Ons

FIVE YEAR SAVINGS $ 72,177.20Add/Choose Add-Ons

Add/Choose Add-Ons$ 1,067.96

$ 18,039.72

SDWAN Fail-Over /Monthly $ 0.00 0

Business HD DECT Cordless PhoneUltra Elegant Gigabit IP PhoneUltra Elegant Touch Screen Gigabit IP Phone

ARE WE PROVIDING PHONE SERVICE

LOSING CARRIER CUSTOMER ID MAIN PHONE #

TERRITORY:

MERCHANT DBA NAME: FEDERAL TAX ID NUMBER MERCHANT ID NUMBER

INTERNET PROVIDER

INTERNET TYPE SEEK

TIME DOWNLOAD

SPEED UPLOAD

SPEED

MS

MEG

MEG

DEAL FLOW BUILDSHEET & TRACKING FORM

Add

Add Type

$ 772.10 60 CIT Yes

NOTES

COMBINED ANNUAL SAVINGS FROM ALL SOURCES

CREDIT | DEBIT | ECHECK $ 1,202.95 $ 14,435.44 $ 72,177.20

UNIFIED COMMUNICATIONS $ 0.00 $ 0.00 $ 0.00

WORKFLOW OPTIMIZATION $ 0.00 $ 0.00 $ 0.00

FIBERCALL HR | TIME & ATTENDANCE $ 0.00 $ 0.00 $ 0.00

INVENTORY MANAGEMENT $ 0.00 $ 0.00 $ 0.00

TOTAL EST. SAVINGS $ 1,202.95 $ 28,870.88 $ 72,177.20Other

TOLL FREE #'s TO PORT LOCAL PHONE NUMBERS TO PORT

CLOVER POS EQUIPMENT AND RELATED PERIPHERILS

Clover Mini WiFi or 3G 2 Clover Mini Clover StationSERIAL NUMBERS TERMIANL ID [TID] SERIAL NUMBERS TERMIANL ID [TID] SERIAL NUMBERS TERMIANL ID [TID]

Clover Flex Clover Go Bluetooth Clover Mobile Dock

SERIAL NUMBERS TERMIANL ID [TID] SERIAL NUMBERS TERMIANL ID [TID] SERIAL NUMBERS TERMIANL ID [TID]

MS DN UP Yes No Inco

mplete

Additional Instructions

BUILDSHEET

Test Internet Speed SEEK | DOWN | UP PASS VoIP? Choose or Add

Cat 5 Currently in Place at Termination Points Choose or Add

Did You Get a Current Telecom Provider Invoice Choose or Add

Did You Get a Current Internet Provider Invoice Choose or Add

Did You Get Current MSP Statements [2/Retail 3/Moto] N/A

Are We Adding Inventory? | Use Drop Down to Chose Method N/A

Did You Get Client Logo | Use Drop Down to Chose Method NA

Do We Need Customer List | Use Drop Down to Explain N/A

Do We Need Employee List | Use Drop Down to Explain N/A

Are we setting up NMI CC Recurring NA

Are we setting up NMI E-Check Recurring NA

Are we adding document portal to Client Website NA

Are we providing client with Customer ACH Authorization Docs NA

Site Survey Verify Wiring N/A

NA

Choose or Add

Choose or Add

Choose or Add

Choose or Add

List all Clover Apps and/or additional software

TOTAL VOLUME $ 90,000.00 TOTAL VOLUME $ 90,000.00

BUNDLED RATE 3.44% BUNDLED RATE 2.04%

TOTAL FEES $ 3,100.00 TOTAL FEES $ 1,838.07

CREDIT ITEMS TREASURY ITEMS DEBIT ITEMS MISC TOTALS

$ 46,200.00 103 $ 19,800.00 44 $ 24,000.00 53 $ 12.00 ON FILE

1.87% $ 0.16 0.50% $ 0.39 0.15% $ 0.27 $ 772.10 TSR

$ 863.94 $ 16.43 $ 99.00 $ 17.16 $ 36.00 $ 14.40 $ 784.10 $ 1,838.07 Subtotal

TAP Discount Offered on Treasury Product|Debit 0.0%$ 0.00 Revenue|DAP

$ 1,838.07 Net Expense

RECALCULATE ENTERPRISE RATE CLASS $ 0.00 $ 58.98 Clover Apps

0.10% TAP Conversion Rate 30% $ 1,897.05 Net Net

CURRENT RETAIL TIER 1 TAP TOTAL VOLUME $ 90,000.00 TOTAL VOLUME $ 90,000.00



STEP UP TO ENTERPRISERETAIL FEES $ 3,100.00

TIER ONE FEES $ 1,897.05

MONTHLY SAVINGS $ 1,202.95


FIVE YEAR SAVINGS $ 72,177.20

YOUR 5 YEAR SAVINGS

$ 72,177.20

ASSUMPTIONS

ASSUMPTIONS BASED ON ACTUAL

NUMBERS FROM CURRENT STATEMENTS

TOTAL VOLUME $ 90,000.00 AVERAGE TICKET $ 450.00

ITEMS 200200 CLIENT REWARDS $ 299.00

TOTAL FEES $ 3,100.00 * DEBIT VOLUME $ 24,000.00

V/MC/DISC VOLUME $ 90,000.00 % DEBIT 27%

AMEX VOLUME $ 0.00 BUNDLED RATE 3.44%

TOTAL VOLUME $ 90,000.00 TOTAL VOLUME $ 90,000.00



STEP UP TO ENTERPRISE

RETAIL FEES $ 3,100.00

TIER ONE FEES $ 1,838.07

MONTHLY SAVINGS $ 1,202.95


FIVE YEAR SAVINGS $ 72,177.20

Service Item Unit Definition Unit NRC NRC Total MRC MRC Total Usage Line

Site Package {incl with ea order} Per site -$ N/A N/A

Auto Attendant {1 incl w/Site Package} Per instance -$ N/A

Call Queue {1 incl w/Site Package} Per queue -$ N/A

Music on Hold {1 incl w/Site Package} Per setup -$ N/A

Premium Station Per station 12.95$ N/A

Standard Station Per station 11.95$ N/A

Basic Station {can be used w/fax machine} Per station 10.95$ N/A

Messaging Station Per station 10.95$ N/A

Auto Attendant {1 incl /add only if add layers req'd} Per instance 5.95$ N/A

Call Queue {1 incl /add only if additional layers req'd} Per queue 5.95$ N/A

Group Paging Per instance 5.95$ N/A N/A

Hunt Group Per instance 5.95$ N/A

Meet-Me Bridge {incl w/Premium Station} Per bridge package instance 5.95$ N/A N/A

Meet-Me Conference {incl w/Premium Station} Per conference host ID instance -$ N/A N/A

Call Recording {a license req'd for ea line to be recorded} Per recorder -$ N/A N/A

Receptionist Client Per client -$ N/A N/A

UC-One Collaboration Bundle {incl w/Premium Station} Per bundle -$ N/A N/A

CRM Connect Per client -$ N/A N/A

E-fax {connection only, not service, station not req'd, line only} Per instance -$ N/A

Toll Free Service MRC per TF#/usage per min 6.95$ 1.95$ 0.039$

Domestic Long Distance Service Unlimited -$ -$ N/A N/A

International Long DistanceUsage per min by country (see rate

sheet)-$ -$ Varies N/A

Directory Assistance Usage per call -$ -$ 1.49$ N/A

Operator Assistance Usage per call -$ -$ 1.49$ N/A

Expedite Order Processing Per order 59.95$ -$ N/A N/A

Port Local Number Per ported number 5.95$ -$ N/A N/A

Additional Phone Number Per new number 1.95$ 1.59$ N/A N/A

Remote User {incl w/Premium & Standard Station} Per remote station 5.95$ -$ N/A N/A

Remove Directory Listing Per order 5.95$ -$ N/A N/A

Change Order after FOC date assignment Per number 2.99$ -$ N/A N/A

Cancel Order after FOC date assignment Per number 2.99$ -$ N/A N/A

ER Order Cancellation {if received less than 48 hr from SAD} Per order 59.95$ -$ N/A N/A

ER Order Change {if received less than 48 hr from SAD} Per order 59.95$ -$ N/A N/A

Change from Remote User Per downgraded number 5.95$ -$ N/A N/A

Change Main Number Per number 5.95$ -$ N/A N/A

Change to Remote User Per number 5.95$ -$ N/A N/A

Change Remote User Address Per Remote station 5.95$ -$ N/A N/A

Disconnect Phone Numbers Per number 5.95$ -$ N/A N/A

Move Site Per number 5.95$ -$ N/A N/A

Telephony Service Quote

Hosted PBX Site Model

Optional Services

Long Distance, International and Related Services

Telephony & PSTN Service Orders

$$

$$

$$

$$

-

-

-

-

Grand Total NRC

Grand Total MRC

Total Lines

Promo / Rebate

NOTES

Tier 1 Business Class Service Order Disclosure:

Tier 1 Monthly Service Charge is quoted based on the information available at the time of signing of the order. The cost of any additional service items and/or modifications requested by a customer in writing or orally not quoted in this Service Order will be added to the customer's monthly service charge based on the pricing indicated in this service order. A customer can remove any additional service items and/or modifications at any time by sending a request in writing. Customer by signing below, agrees and accepts the said Terms and Conditions.

Signature: ___________________________

fibercall

1

1

1

$ 0.00

$ 0.00 $ 8.00$ 0.00$ 0.00 $ 18.90$ 0.00$ 0.00 $ 19.80$ 0.00

1

$ 0.00 $ 23.40$ 0.00

1$ 0.00

1

1

$ 0.00

$ 0.00

$ 0.00

$ 0.00

$ 6.00

$ 0.00$ 0.00

$ 18.00

$ 0.00

$ 0.00

$ 5.00

$ 0.00$ 0.00

$ 13.00

$ 0.00

$ 12.00

$ 0.00$ 0.00

$ 10.00

$ 0.00

$ 7.00

$ 0.00

$ 0.00 $ 13.00$ 0.00

$ 0.00 $ 7.00$ 0.00

$ 0.00 $ 7.00$ 0.00

$ 0.00 $ 0.00$ 0.00$ 0.00

1

$ 0.00$ 0.00

$ 0.00

$ 0.00$ 0.00

$ 0.00$ 0.00

$ 0.00$ 0.00$ 0.00

$ 0.00$ 0.00

$ 0.00

$ 0.00$ 0.00

$ 0.00$ 0.00

$ 0.00$ 0.00

$ 0.00$ 0.00

$ 0.00$ 0.00

$ 0.00$ 0.00

$ 0.00$ 0.00

$ 0.00$ 0.00

$ 0.00$ 0.00

$ 0.00$ 0.00

$ 0.00$ 0.00

$ 0.00$ 0.00$ 0.00$ 0.00

100% $ 0.00

$ 0.00

$ 0.00 3

$ 0.00

BEAT $ 0.00

TIER ONE $ 0.00

Units INCL

TPSR $ 0.00

MONTHLY SAVINGS $ 0.00

ANNUAL SAVINGS $ 0.00

10/19/2017

Enhanced Interchange Pricing All transactions will be processed in at our blended Interchange pricing plus .... &

Premium Price Guarantee The fees reflected in the Merchant Processing Application will remain at the Enhanced Interchange pricing model indicated above. YES No

Miscellaneous:

For Merchant Name Title Date

Application Fee $ 150Setup/Training Fee Programming Fees $ 450Encryption Fee $ 293Starter KitUPS (Battery Backup) $ 47WiFi Configuration $ 2510/100 IP Switch $ 39Cat 6 IP Cables (Per Unit) $ 36PCI COMPLIANCE Audit $ 168Stress Test $ 315

Total Startup Fees $1,573PCI Compliance Audit Verified

Startup Fees Waived

Equipment Solutions - On Time

Start Up Expenses

Waived

50$

Base10 Pricing Model Interchange Division 110 SE 6th Street 17th Floor

Ft. Lauderdale, FL 33301

Local # (954) 256 5359

0.10% $ 0.06

Tier 1 Enterprise Services 1 $ 772.10

Clover Mini WiFi or 3G INCL

Clover Mobile INCL

Clover Station INCL

Clover Flex INCL

Clover Go Bluetooth INCL

Clover Mobile Dock INCL

Clover Mobile Printer INCL

Clover Cash Drawer INCL

Clover Flex Kit INCL

FUNDS DUE AT STARTUP $ NoneClover Go Stand INCL

NOTE: INCL

INCL

Ultra Elegant Touch Screen Gigabit IP Phone INCL

Ultra Elegant Gigabit IP Phone INCL

Business HD DECT Cordless Phone INCL

To merchant for previous cancellation fees: $ 299.00

LT1250CONFROOM Deluxe INCL

Edgemark 2900E INCL

Cancellation fee if canceled prior to 60 months: $ 299.00

INCL

INCL

INCL

INCL

Total Units / Monthly TSR 1 $ 772.10

Tier 1 Support Applications Manager

ATTACH DRIVERS LICENSE HERE

Tier 1 Support

[email protected]

(954) 320-4070

1

This Enhanced Interchange Premium Price Guarantee, (Agreement) is entered into as of this by and between ___________________________________(“Merchant”) and National Processing Alliance, INC. d/b/a NPA (collectively "Parties").

1. Recitals

1.1 Whereas Merchant desires to avail itself of the benefits of the pricing and rates as shown in the Merchant Processing Application, which is made

part hereof for all purposes.

1.2 Whereas NPA, in exchange for good and valuable consideration as dictated herein, desires to offer to Merchant and maintain the prices and rates as

shown in the Merchant Processing Application.

2. Payment & Billing

2.1 In consideration for NPA providing and maintaining the pricing and rates as shown in the Merchant Processing Application, Merchant hereby

agrees to process its credit and/or debit card transactions exclusively with NPA for a term of 60 months (“Exclusive Term”).

2.2 In consideration for Merchant’s maintenance of the Exclusive Term, NPA guarantees that the discount rates reflected in the Merchant Processing

Application, will not be higher than ten basis points above our interchange blended rate during the initial 60month term of this agreement. 2.3 Additionally, in consideration for the Exclusive Term, NPA agrees to waive “Start Up Fees” noted on the Enhanced Interchange Pricing Model

document, which is made part hereof for all purposes. These fees are considered earned on date of signing.

2.4 NPA will debit merchants DDA account 42.50 two times a year as a maintenance fee. Merchant may opt out of the 42.50 payment by crossing out

this paragraph.

3. Miscellaneous3.1 Merchant further acknowledges that no other agreements or stipulations have been made either verbal or otherwise and that these agreements represent the entire agreement.

3.2 Lifetime equipment guarantee: equipment is hereby conditionally guaranteed for the life of the agreement (see equipment guarantee). 4. Breach of Agreement and Disputes

4.1 Merchant acknowledges that the waived fees in section 2.3 represent costs to Company, in the event that Merchant terminates, or breaches this agreement, prior to the contractual term, all waived fees will become immediately due and payable. Merchant further acknowledges that company is not

a representative of, or affiliated in any way with their current bank. Any lease agreements entered into by merchant as a result of this or any other

agreement will continue regardless of the processing status of the merchant with company.

4.2 Merchant further acknowledges and understands that upon Merchants execution of this agreement NPA, to ensure Merchant’s rates and service, will enter into an agreement with an equipment leasing company and third party processor. Merchant acknowledges and understands that these

agreements will require NPA to expend time and money for setup and acquisition of equipment and that NPA will receive third party compensation as

a result of those expenditures in conjunction with Merchant’s compliance with, and maintenance of this agreement. In the event that Merchant terminates

or breaches this agreement prior to the contractual term, Merchant acknowledges that NPA is entitled to recover from Merchant, the amount that NPA

reasonably expected to receive from those contracts as a result of the agreements with the third party processor and Equipment Lease Company,

depending on the term.

4.3 Mandatory Arbitration: Unless otherwise stated in this Contract, any “Dispute” shall, be resolved by a neutral, binding arbitration. This arbitration agreement applies to the Parties, including their respective employees or agents, as to all matters which arise out of or relate to this Contract, or any

resulting transaction or relationship. The term “Dispute” means any action, dispute, claim, or controversy of any kind arising out of, in connection with

or in any way related to this Agreement. The term “Dispute” includes, without limitation: claims under federal or state consumer protection laws; claims

in tort or contract; claims under statutes or common law; claims at law or in equity; any other past, present or future claims, counterclaims, crossclaims, third party claims, interpleaders or otherwise; and any claim relating to the interpretation, applicability, enforceability or formation of this arbitration agreement, including but not limited to, any claim that all or part of this arbitration agreement, is void, voidable or unconscionable. You can obtain

information about arbitration at the website of the American Arbitration Association (“AAA”) (www.adr.org). Any arbitration will be administered by

the AAA in accordance with the Federal Arbitration Act, 9 U.S.C. §§ 1, et seq. (“FAA”). The AAA rules may be obtained by mail by telephone at 8007787879 or on the internet at www.adr.org. The arbitration will be conducted under the applicable AAA rules unless those rules are inconsistent with this arbitration agreement, in which case this arbitration agreement shall govern. In any arbitration, the arbitrator shall apply the law and the provisions

of this arbitration agreement in deciding any Dispute. Unless the applicable rules provide otherwise, the arbitration award shall be issued without a

written opinion. The arbitration hearing shall be conducted in Broward County, Florida where. The Parties agree that the Contract and purchase of the

Property involves interstate commerce and that this arbitration agreement is governed by the FAA. The arbitrator shall strictly apply applicable Florida

law and statutes of limitation consistent with the FAA. Judgment upon any arbitrator’s award may be entered by any court having competent jurisdiction.

0.10%

Val VassermanHighlight



2

The Parties hereby agree to give up their respective rights to a trial by a jury. The Parties agree to give up any right they may have to bring a class action

lawsuit or class arbitration, or to participate in either as a claimant. The Parties agree to give up any right to consolidate or join any arbitration proceeding

with the arbitration of others. To the extent the Parties are permitted to file small claims, the Parties agree that any small claim may only be brought on

an individual basis and that no small claim may be brought on a class or representative basis. The Parties agree that this arbitration agreement is not

applicable to “small claims” meaning those claims that either Party is entitled to file and maintain in an appropriate small claims court, including any

claims for attorney’s fees and nonmonetary relief. Any small claims suit brought by a party shall be exclusively in the County Court in and for Broward County Florida and governed by the Laws of the State of Florida. If it is determined that any paragraph or provision in this arbitration agreement is

illegal, invalid, or unenforceable, such illegality, invalidity or unenforceability shall not affect the other paragraphs and provisions of this arbitration

agreement. The remainder of this arbitration agreement shall continue in full force and effect. This arbitration agreement will survive and continue in

full force and effect notwithstanding cancellation, termination, amendment, payment in full, discharge in bankruptcy, or other expiration or conclusion

of the Contract or any other contract or transaction between the Parties, unless otherwise agreed in writing. In addition, Merchant understands and

acknowledges that the rights and responsibilities afforded to NPA under this arbitration agreement survive any assignment of the Contract by NPA and

that NPA can enforce this arbitration agreement in the event a Dispute arises after the assignment of the Contract. If you do not want this arbitration

agreement to apply, you may reject it by mailing us a written notice stating so. A rejection notice is only effective if it is signed by Merchant, and the

envelope that the rejection notice is sent in is postmarked no more than 20 calendar days after the date of the Contract. Even if you reject this arbitration

agreement, the remaining aspects of the arbitration agreement with regard to class actions and consolidation shall remain valid and effective, and will

be incorporated into the Contract. If you reject this arbitration agreement, it will not affect any other provisions of the Contract or your obligations

under the Contract. If you do not properly reject this arbitration agreement, it will be effective as of the date of the Contract. FOR ALL DISPUTES

COVERED BY THIS ARBITRATION AGREEMENT, THE PARTIES HAVE AGREED TO WAIVE THEIR RIGHT TO A TRIAL BY JURY AND

THEIR RIGHT TO PARTICIPATE IN CLASS ACTIONS. EXCEPT FOR DISPUTES AND CLAIMS NOT SUBJECT TO THIS ARBITRATION

AGREEMENT. THE TERMS OF THIS AGREEMENT AFFECT YOUR LEGAL RIGHTS. IF YOU DO NOT UNDERSTAND ANY TERMS OF THIS

PROVISION OR THE COST, ADVANTAGES OR DISADVANTAGES OF ARBITRATION, SEEK INDEPENDENT ADVICE AND/OR CONTACT

THE AMERICAN ARBITRATION ASSOCIATION AT (800) 7787879 BEFORE SIGNING THIS CONTRACT. IN ANY DISPUTE TO ENFORCE THE TERMS OF THIS AGREEMENT, THE PREAVILAING PARTY SHALL BE ENTITLED TO REASONABLE ATTORNEYS FEES AND COSTS.

BY SIGNING THIS CONTRACT, YOU ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTAND AND AGREE.

Merchant

Printed Name and Title Signature Date

NPA

Valeriya Vasserman, Vice President

Printed Name and Title Signature Date

OmahaWF1904(ia)

OmahaWF1904(ia) CONFIRMATION PAGE

1. Your Discount Rates are assessed on transactions that qualify forcertain reduced interchange rates imposed by MasterCard, Visa,Discover and PayPal. Any transactions that fail to qualify for thesereduced rates will be charged an additional fee (see Section 25 of theProgram Guide).

2. We may debit your bank account (also referred to as your SettlementAccount) from time to time for amounts owed to us under the Agreement.

3. There are many reasons why a Chargeback may occur. When theyoccur we will debit your settlement funds or Settlement Account. For amore detailed discussion regarding Chargebacks see Section 14 of theYour Payments Acceptance Guide or see the applicable provisions of theTeleCheck Services Agreement.

4. If you dispute any charge or funding, you must notify us within 60days of the date of the statement where the charge or funding appearsfor Card Processing or within 30 days of the date of a TeleChecktransaction.

5. The Agreement limits our liability to you. For a detailed descriptionof the limitation of liability see Section 27, 37.3, and 39.10 of the CardGeneral Terms; or Section 1.14 of the TeleCheck Services Agreement.

6. We have assumed certain risks by agreeing to provide you with Cardprocessing or check services. Accordingly, we may take certain actions tomitigate our risk, including termination of the Agreement, and/or hold moniesotherwise payable to you (see Card Processing General Terms in Section 30,Term; Events of Default and Section 31, Reserve Account; Security Interest),(see TeleCheck Services Agreement in Sections 1.1, 1.3.2, 1.3.9, 1.6), undercertain circumstances.

7. By executing this Agreement with us you are authorizing us and ourAffiliates to obtain financial and credit information regarding your businessand the signers and guarantors of the Agreement until all your obligations tous and our Affiliates are satisfied.

8. The Agreement contains a provision that in the event you terminate theAgreement prior to the expiration of your initial three (3) year term, you willbe responsible for the payment of an early termination fee as set forth in PartIV, A.3 under “Additional Fee Information” and Section 1 of the TeleCheckServices Agreement.

9. If you lease equipment from Processor, it is important that you reviewSection 1 in Third Party Agreements. Bank is not a party to this Agreement.THIS IS A NON-CANCELABLE LEASE FOR THE FULL TERM INDICATED.

10. Card Organization Disclosure

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

The Bank’s mailing address is 1200 Montego, Walnut Creek, CA 94598, and its phone number is (925) 746-4143.

Print Client’s Business Legal Name:__________________________________________________________________________________________________

By its signature below, Client acknowledges that it has received the Merchant Processing Application, Program Terms and Conditions [version

OmahaWF1904(ia)] consisting of 52 pages [including this Confirmation Page and the applicable Third Party Agreement(s)].

Client further acknowledges reading and agreeing to all terms in the Program Terms and Conditions. Upon receipt of a signed facsimile or

original of this Confirmation Page by us, Client’s Application will be processed.

NOALTERATIONS OR STRIKE-OUTSTOTHE PROGRAM TERMS AND CONDITIONS WILL BE ACCEPTED.

Client’s Business Principal:

Signature (Please sign below) :

X ____________________________________________________________ ____________________________________ ________________Title Date

______________________________________________________________________________

Please Print Name of Signer

Important Member Bank Responsibilities:

a) The Bank is the only entity approved to extend acceptance of Visa

and MasterCard products directly to a merchant.

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

c) 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.

d) The Bank is responsible for and must provide settlement funds to

the merchant.

e) The Bank is responsible for all funds held in reserve that are

derived from settlement.

f) The Bank is the ultimate authority should a merchant have any

problems with Visa or MasterCard products (however, Processor

also will assist you with any such problems).

Important Merchant Responsibilities:

a) Ensure compliance with Cardholder data security and storage requirements.

b) Maintain fraud and Chargebacks below Card Organization thresholds.

c) Review and understand the terms of the Merchant Agreement.

d) Comply with Card Organization Rules and applicable law and regulations.

e) Retain a signed copy of this Disclosure Page.

f) You may download “Visa Regulations” from Visa’s website at:https://usa.visa.com/support/merchant.html.

g) You may download “MasterCard Regulations” from MasterCard’s website at:http://www.mastercard.com/us/merchant/support/rules.html.

h) You may download “American Express Merchant Operating Guide” fromAmerican Express’ website at: www.americanexpress.com/merchantopguide.

PROCESSOR Name:___________________________________________________________________________________________________________________

INFORMATION:Address: _________________________________________________________________________________________________________________

URL: _______________________________________________________________ Customer Service #:_________________________________

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 or the contents of yourAgreement with TeleCheck. The following information summarizes portions of your Agreement in order to assist you in answering some of thequestions we are most commonly asked.

First Data Merchant Services

1307 Walt Whitman Road, Melville, NY 11747

1-800-858-1166

Merchant Initials: ________

■ INDIVIDuAL /SOLE PROPRIETORSHIP: State in which Certificate of

Assumed Name Filed: _____________________________ State:_______

■ CORPORATION – CHAPTER S, C State:_______

■ MEDICAL OR LEGAL CORPORATION State:_______

1. BUSINESS INFORMATION

Client’s Business Name (Doing Business As): Client’s Corporate/Legal 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 Address: Contact Fax # / E-mail Address:

Business Website Address: Contact Phone #:

Customer Service Phone #: Customer Service E-mail Address: Send Retrieval Requests to: ■ Business Location ■ Corp/Legal LocationSend Merchant Monthly Statement to: ■ Business Location ■ Corp/Legal Location

Date Business Started:

■ TAx ExEMPT ORGANIZATION (501C) State:________

■ INTERNATIONAL ORGANIZATION

Location Filed:_________________________________

■ ASSOCIATION/ESTATE/TRuST State Filed:________

■ GOVERNMENT (Federal, State, Local)

■ LIMITED LIABILITYCOMPANY State Filed:________

■ PARTNERSHIP State Filed:________

1. Zone: ■ Business District ■ Industrial ■ Residential

2. Location: ■ Mall ■ Office ■ Home ■ Shopping Area

■ Apartment ■ Isolated ■ Door-to-Door

■ Flea Market ■ Other

3. How many employees: ____________

4. How many registers/Terminals: ____________

5. Is proper license visible? ■ Yes

■ No, explain:_____________________________________________

6. Where is the merchant name displayed at the site?

■ Window ■ Door ■ Store Front

7. Merchant Occupies: ■ Ground Floor ■ Other: _________________

8. # of Floors/Levels: ■ 1 ■ 2-4 ■ 5-10 ■ 11+

9. Remaining Floor(s) Occupied by:

■ Residential ■ Commercial ■ Combination ■ None

10. Approximate Square Footage:

■ 0-250 ■ 251-500 ■ 501-2,000 ■ 2,001 plus

11. Are customers required to leave a deposit?

■ No ■ Yes If Yes, % of deposit required: _______%

12. Return Policy: ■ Full Refund ■ Exchange Only ■ None

13. Do you have a refund policy for MC/Visa /

Discover® Network - PayPal/American Express OptBlue® Sales?

■ Yes ■ No If yes, check one:

■ Exchange ■ MC/Visa /Discover Network - PayPal/

■ Store Credit American Express OptBlue® Credit

If MC/V/Discover Network - PayPal/American Express OptBlue® Credit, within how many

days do you submit credit transactions?

■ 0-3 ■ 4-7 ■ 8-14 ■ Over 14

14. Advertising Method (Attach at least one):

■ Catalog ■ Brochure ■ Direct Mail ■ TV/Radio

■ Internet ■ Phone ■ Newspaper/Journals ■ Other

Marketing Materials required for Mail Order, B to B, Internet over $1 Million in annual volume. Attach Web Page for Internet Merchant.

15. Previous Processor:______________________________________________________________

16. Check Reason For Leaving: ■ Rate ■ Service ■ Terminated ■ Other: _________________

Mail /Telephone Order/Business to Business/Internet Information(All Questions must be Answered)

1. What is the time frame from transaction to delivery? (% of orders delivered in):

0-7 days______% + 8-14 days______% + 15-30 days______% + over 30 days______% = 100%

2. MC/Visa /Discover Network - PayPal/American Express OptBlue® sales are deposited (check one):

■ Date of order ■ Date of delivery ■ Other (specify): ________________________________

3. Does any of your cardholder billing involve automatic renewals or

recurring transactions (i.e., cardholder authorizes initial sale only)? ■ Yes ■ No

2. ADDITIONAL CREDIT / SITE SURVEY INFORMATION – ALL MERCHANTS

Name (as it appears on your income tax return) FEDERAL TAX ID # ■ I certify that I am a foreign entity/nonresident alien.(as it appears on your income tax return) (If checked, please attach IRS Form W-8.)

NOTE: Failure to provide accurate information may result in a withholding of merchant funding per IRS regulations. (See Part IV, Section A.4 of your Program Guide for further information.)

*SIC/MCC: IATA/ARC: (MCC 4722 Only)

Note: *If your business is classified as High Risk and assigned (or is later assigned based upon your business activity) any of the following Merchant Category Codes (MCC): 5966, 5967 and 78411,then registration is required with Visa and/or MasterCard within 30 days from when your account becomes active. An Annual Registration Fee of $500 may apply for Visa and/or MasterCard (total registration feescould be $1,000.00). Failure to register could result in fines in excess of $10,000.00 for violating Visa and/or MasterCard regulations2.1Registration for MCC 7841 is only required for non-face-to-face adult content.2 Information herein, including applicable MCCs, is subject to change.

Detailed Explanation of Type of Merchandise, Products or Services Sold:

MERCHANT PROCESSING APPLICATION AND AGREEMENT

Sales Office____________________________________ Print Sales Rep Name _________________________________________________ Sales ID# ________________________________

Merchant Number_______________________________ Sales Rep. Signature __________________________________________________ Phone #: ________________________________

OmahaWF2004(ia)OmahaWF2004

Page 1 of 6

NPA Valeriya Vasserman 1860/2700

(954) 320-4070

NA

NA

■

■

✔

✔

✔

✔

✔ 0

✔

✔

✔

✔

✔

✔ ✔

✔

✔

✔

✔ ✔

✔ ✔

100

✔ 30 day net after product received

✔

DBA Name: _________________________________________________________________________ Merchant #: _____________________________________ Page 2 of 6

3. OWNERS / PARTNERS / OFFICERS

OWNER / PARTNER / OFFICER 1 OWNER / PARTNER / OFFICER 2

Name: (First, MI, Last) % Ownership: Name: (First, MI, Last) % Ownership:

Title: Title:

Home Address: (No P.O. Box) Home Address: (No P.O. Box)

City: State: Zip: Country: City: State: Zip: Country:

Telephone #: Social Security #: Telephone #: Social Security #:

D.O.B.: DL #: State: D.O.B.: DL #: State:

4. SETTLEMENT INFORMATION

Deposit Bank:

Transit /ABA #: Deposit Account #:

ACH Detail Flag: ■ Individual ■ Combined ■ Separate (defaults to Combined if option not selected)

OmahaWF2004 OmahaWF2004(ia)

MC CREDIT ___________________MPG ID 8-pos. Alpha/Numeric

MC DEBIT ___________________MPG ID 8-pos. Alpha/Numeric

VISA CREDIT ___________________MPG ID 8-pos. Alpha/Numeric

VISA DEBIT ___________________MPG ID 8-pos. Alpha/Numeric

DISCOVER NETWORK - PayPal ___________________CREDIT MPG ID 8-pos. Alpha/Numeric

DISCOVER NETWORK ___________________DEBIT MPG ID 8-pos. Alpha/Numeric

6. GRID INFORMATION – INTERNAL USE ONLY

7. SERVICE FEE SCHEDULE

AuTHORIZATION GRID ID#: _________________ uSER DEFINED GRID ID#: _________________ MFC GRID ID: _________________ 8-pos. Alpha/Numeric

AMERICAN ExPRESS ___________________OptBlue® CREDIT 8-pos. Alpha/NumericMPG ID

MC TIERED ___________________GRID ID 8-pos. Alpha/Numeric

VISA TIERED ___________________GRID ID 8-pos. Alpha/Numeric

DISCOVER NETWORK - PayPal ___________________TIERED GRID ID 8-pos. Alpha/Numeric

AMERICAN ExPRESS ___________________OptBlue® TIERED 8-pos. Alpha/NumericGRID ID

Accept all MasterCard, Visa, Discover Network and American Express OptBlue® Transactions (presumed, unless any selections below are checked)

MasterCard Visa Discover Network American Express OptBlue®

■ MC Credit Transactions ■ Visa Credit Transactions ■ Discover Network Credit Transactions ■ American Express Credit Transactions

■ MC Non-PIN Debit Trans. ■ Visa Non-PIN Debit Trans. ■ Discover Network Non-PIN Debit Trans.

Discover Network - PayPal

■ Discover Network - PayPal Credit Transactions■ Discount Collected ■ Daily ■ Monthly


5. TRANSACTION INFORMATION

WHERE IS SALETRANSACTED?

(Must = 100%)

Store Front /Swiped ________%

Internet ________%

Mail Order ________%

Telephone Order ________%

Total ________%

Gross YEARLY Sales Volume (Cash + Credit + Debit + Check) $_____________

Average YEARLY MC/Visa Volume $_____________

Average YEARLY Discover Network - PayPal Volume $_____________

Average YEARLY American Express OptBlue® Volume $_____________

Seasonal? ■ No ■ Yes High Volume Months Open: _____________________________________________________________________

Avg. MC/Visa /Discover Network - PayPal Ticket (Estimate If Never Processed in Past) $_____________

Avg. American Express OptBlue® Ticket (Estimate If Never Processed in Past) $_____________

Highest Ticket Amount $_____________

FINANCIAL DATA

100

Tiered

Discount Fees (Based on Gross Sales Volume)

Discount MPG TxN Fee Discount MPG TxN Fee Discount MPG TxN Fee Discount MPG TxN Fee

MCQual Credit % $

VisaQual Credit % $

Discover Network -PayPal Qual Credit % $

American ExpressOptBlue® Qual Credit % $

MCMid-Qual Credit % $

VisaMid-Qual Credit % $

Discover Network -PayPal Mid-Qual Credit % $

American ExpressOptBlue® Mid-Qual Credit % $

MC Non-Qual Credit % $

Visa Non-Qual Credit % $

Discover Network -PayPal Non-Qual Credit % $

American ExpressOptBlue® Non-Qual Credit % $

MC WorldcardQual % $ Visa Rewards 1 % $

MC WorldcardMid-Qual % $ Visa Rewards 2 % $

MC WorldcardNon-Qual % $

MCQual Debit % $

VisaQual Debit % $

Discover NetworkQual Debit % $

MCMid-Qual Debit % $

VisaMid-Qual Debit % $

Discover NetworkMid-Qual Debit % $

MCNon-Qual Debit % $

VisaNon-Qual Debit % $

Discover NetworkNon-Qual Debit % $

MC RegulatedDebit Discount % $

Visa RegulatedDebit Discount % $

Discover NetworkRegulated Debit Disc’t % $

100

USA 0

✔

0.00 450.00

972,000.00

0.00

450.00

108,000.00

✔

✔ ✔ ✔ ✔

✔ ✔ ✔

✔

NA NA NA NA NA NA

NA NA NA NA NA NA

NA NA

NA NA NA NA NA NA

NA NA

NA NA NA NA

NA NA NA NA

NA NA

NA NA

NA NA NA NA NA NA

NA NA NA NA NA NA

NA NA NA NA NA NA

NA NA NA NA 0 NA

✔

7. SERVICE FEE SCHEDULE (cont’d)




Authorization & Capture Transaction Fees

MC/Visa Auth & Capture Fee: $_________ (per item)

Discover Network PayPal Auth & Capture Fee: $_________ (per item)

American Express OptBlue® Auth & Capture Fee: $_________ (per item)

American Express Pass Through (existing) SE #: ___________________________

Voice Authorization $_________ (per item)

Electronic AVS Fee $_________ (per item)

Voice AVS Fee $_________ (per item)

ARu Fee $_________ (per item)

Payeezy Gateway TeleCheck Auth Fee $_________

(per item)

First Data PayeezySM Gateway Services

■ Payeezy Gateway ParticipationPayeezy Gateway Effective Date: _________________

Payeezy Gateway One Time Setup Fee $________ (one time)

Payeezy Gateway Monthly Fee $________ (monthly)

Payeezy Gateway Auth Fee $________ (per item)

Payeezy Gateway AVS Fee $________ (per item)

Payeezy PayPal Auth Fee $________ (per item)

Payeezy PayPal Sale Fee $________ (per item)

Payeezy PayPal Return Fee $________ (per item)

First Data PayeezySM Gateway Services Telecheck

Fleet

WEX: Other Item Rate $________ (per item) Voyager: Qual ________% Other Item Rate $________ (per item)

PIN Debit

■ Pass Through Debit Network Fees Other Item Rate $__________ (per item) Other Volume Percent _________% (per item)

TeleCheck

ECA Warranty ■ Mail Order Warranty ■ Single Hold Check Warranty ■ Multiple Hold Check Warranty ■ Paper Warranty ■ C.O.D. Warranty SE # ___ ___ ___ ___ ___ ___ ___ ___

Inquiry Rate ________%

Dec. Risk Surcharge ________%

Per TxN Fee $________

Monthly Minimum Fee $________ (Per Location)

Stmt/Processing Fee $________

Customer Requested Operator Call (CROC) $________

ECA Chargeback Fee $________

Other Item Rate

MC Credit $ Visa Credit $Discover Network -PayPal Credit $

American ExpressOptBlue® Credit $

MC Debit $ Visa Debit $Discover NetworkDebit $

Other Volume %

MC Credit % Visa Credit %Discover Network -PayPal Credit %

American ExpressOptBlue® Credit %

MC Debit % Visa Debit %Discover NetworkDebit %

ERR

Discount Non-Qual Fees Discount Non-Qual Fees Discount Non-Qual Fees Discount Non-Qual Fees

MC Qual Credit % % Visa Qual Credit % %Discover Network -PayPal Qual Credit % %

American ExpressOptBlue® Qual Credit % %

MC Qual Debit % % Visa Qual Debit % %Discover NetworkQual Debit % %

Pass Through Interchange

Net Only - Includes Dues and Assessments Gross Only - Includes Dues and Assessments

Discount (Basedon Gross Sales Vol.)




MC Qual Credit % Visa Qual Credit % Discover Network - PayPal Qual Credit % American Express OptBlue® Qual Credit %

MC Qual Debit % Visa Qual Debit % Discover Network Qual Debit %American Express OptBlue® has Program Pricing and notInterchange and are subject to change.

■ Dues and Assessments V/MC Chargeback V/MC Retrieval Return Trans. Fee (Per Item) $_________ Fee (12B Letter) (Per Item) $_________ Fee (Per Item) $_________

Sales Transaction Early Termination Fee (Per Item) $_________ Batch Fee (Per Item) $_________ Fee (One Time Fee) $_________ elDS Access Fee (Flat Rate) $_________

EBT – EBT – Other: Food Stamps (Per Item) $_________ #: __________________________ Cash Benefits (Per Item) $_________ _______________________ $_________

Monthly Statement Fee Pass Visa Minimum Monthly Fee $_________ (Acct on File) $_________ ACH Reject Fee (Per Item) $_________ Trans Integrity Fee ■ Yes ■ No

MC License Fee ■ Monthly(Per Sales Item) $_________ (Sales Volume) _________% (Flat Rate) $_________ ■ Annually in December

Visa Proc Fee (Per Item) $_________ MC Proc Fee (Per Item) $_________ Visa BIN Fee (Per Item) $_________ MC ICA Fee (Per Item) $_________

Pass Visa Fixed Acquirer Network Fee (FANF) ■ Yes ■ No Visa FANF Card Present Surcharge (Flat Rate) $_________ Visa FANF Card Not Present Surcharge (Flat Rate) $_________

Pass Visa Pass Visa Pass Visa Pass VisaAcquirer Processing Fee ■ Yes ■ No Misuse of Auth Fee ■ Yes ■ No Zero Floor Limit Fee ■ Yes ■ No Int’l Acquirer Fee ■ Yes ■ No

Pass MC Pass MC Pass Discover Pass Visa Acquirer Support Fee ■ Yes ■ No Cross Border Fee ■ Yes ■ No Data usage Charge ■ Yes ■ No Acq ISA Fee ■ Yes ■ No

Pass MC Pass Discover Pass Discover Pass MC Nat’l AcquirerProc Integrity Fee ■ Yes ■ No Int’l Proc Fee ■ Yes ■ No Int’l Service Fee ■ Yes ■ No Brand usage (NABu) Fee ■ Yes ■ No

Miscellaneous Fees

Payeezy Gateway TeleCheck Deposit Fee $_________

(per item)

Payeezy Gateway TeleCheck Adjustment Fee $_________

(per item)

5.00

2.50

5.00

.10

NA NA NA NA NA NA

NA NA NA NA NA NA

NA NA

✔

0.10% 0.10% 0.10% 0.30

0.10% 0.10% 0.10%

NA NA NA NA

NA NA NA NA NA

NA NA NA NA

NA NA NA NA NA

✔ $ 0.06 0.10%

NA NA NA

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

25.00 15.00 NA

NA 0.20 $ 299.00 NA

0.06 NA NA NA NA

25.00 $ 12.00

NA NA NA

NA NA NA NA

NA NA

✔

35.00

$ 0.06

$ 0.06

$ 0.20

2.00

0.05

0.99

0.65

NA

NA

NA

NA

NA

NA

NA

NA NA NA





Pass Visa Account Verification Fee ■ Yes ■ No Visa Account Verification Fee Surcharge (Per Item) $_________

Pass VISA BIN / ICA Fee(Note: this fee can only be used for Shared Systems Only) ■ Yes ■ No VISA BIN / ICA Fee Surcharge (Per Item) $_________

Pass Visa Staged Digital Wallet Fee ■ Yes ■ No Visa Staged Digital Wallet Fee Surcharge (Per Item) $_________

Pass Visa B2B Virtual Payments Fee ■ Yes ■ No Visa B2B Virtual Payments Fee Surcharge (Sales Volume) _________%

Pass Visa File Transmission Fee ■ Yes ■ No Visa File Transmission Transaction Fee Surcharge (Per Item) $_________

Pass Visa Acquirer Credit Voucher Data Processing Fee ■ Yes ■ No Visa Acquirer Credit Voucher Data Processing Fee Surcharge (Per Item) $_________

Pass Visa AFD Non Participation Fee ■ Yes ■ No Visa AFD Non Participation Fee Surcharge (Per Item) $_________

Pass Discover Card Account Verification Fee ■ Yes ■ No Discover Card Account Verification Fee Surcharge (Per Item) $_________

Pass Discover Network Auth Fee ■ Yes ■ No Discover Network Auth Fee Surcharge (Flat Rate) $_________ or (Per Item) $_________

Discover Dispute Fee (Per Item) $_________ Discover Retrieval Fee (Per Item) $_________

Pass PayPal Participation Authorization Fee ■ Yes ■ No PayPal Participation Authorization Fee Surcharge (Sales Volume) _________%

Pass American Express OptBlue® Access Fee ■ Yes ■ No

Pass American Express OptBlue® Network Fee ■ Yes ■ No American Express OptBlue® Network Fee Surcharge (Sales Volume) _________%

American Express Dispute Fee (Per Item) $_________ American Express Retrieval Fee (Per Item) $_________

Pass MasterCard Processing Integrity Fee Pre Auth ■ Yes ■ No MasterCard Processing Integrity Fee Pre Auth Surcharge (Per Item) $_________

Pass MasterCard Processing Integrity Fee undefined Auth ■ Yes ■ No MasterCard Processing Integrity Fee undefined Auth Surcharge (Per Item) $_________

Pass MasterCard Processing Integrity Fee Final Auth ■ Yes ■ No MasterCard Processing Integrity Fee Final Auth Surcharge (Per Item) $_________

Pass MasterCard BIN / ICA Fee(Note: this fee can only be used for Shared Systems Only) ■ Yes ■ No MasterCard BIN / ICA Fee Surcharge (Per Item) $_________

Pass MasterCard Account Status Fee ■ Yes ■ No MasterCard Account Status Fee Surcharge (Per Item) $_________

Pass MasterCard Kilobyte Fee ■ Yes ■ No MasterCard Kilobyte Fee Surcharge (Flat Rate) $_________ or (Per Item) $_________

Pass MasterCard CVC2 Fee ■ Yes ■ No MasterCard CVC2 Fee Surcharge (Flat Rate) $_________ or (Per Item) $_________

Pass MasterCard ICA AVS Fee ■ Yes ■ No MasterCard ICA AVS Fee Surcharge (Per Item) $_________

Pass MasterCard Digital Enablement Fee ■ Yes ■ No MasterCard Digital Enablement Fee Surcharge (Sales Volume) _________%

Pass MasterCard Business to Business uS ■ Yes ■ No MasterCard Business to Business uS Surcharge (Sales Volume) _________%

Pass MasterCard SecureCode Transaction Fee ■ Yes ■ No MasterCard SecureCode Transaction Fee Surcharge (Flat Rate) $_________

Pass MasterCard Location Fee ■ Yes ■ No MasterCard Location Fee Surcharge (Flat Rate) $_________

Pass STAR Debit Network Annual Fee ■ Yes ■ No STAR Debit Network Annual Fee Surcharge (Flat Rate) $_________

Pass Pulse Debit Network Annual Fee ■ Yes ■ No Pulse Debit Network Annual Fee Surcharge (Flat Rate) $_________

Pass Jeanie Debit Network Annual Fee ■ Yes ■ No Jeanie Debit Network Annual Fee Surcharge (Flat Rate) $_________

Pass NYCE Debit Network Annual Fee ■ Yes ■ No NYCE Debit Network Annual Fee Surcharge (Flat Rate) $_________

Pass Accel Debit Network Annual Fee ■ Yes ■ No Accel Debit Network Annual Fee Surcharge (Flat Rate) $_________

Merchant Fee Control Grid Fees

Annual Fee $_________ Other: ______________________________ $_________ Other: ______________________________ $_________

Month _______________ ■ Per item ■ Monthly ■ Annually Month __________ ■ Per item ■ Monthly ■ Annually Month ____________

TIN/TFN & Regulatory Product Fees

Reg. Product Fee (Monthly) $________

TIN /TFN Invalid (Monthly) $________

Website usage (Per Item) $________

User Defined Grid Fees

Wireless Monthly Service Fee $_________ AccessOne Fee $_________

Customer Service Fee $_________ Debit Access Fee $_________

Supplies: ___________________________ $_________ Other: ________________________ $_________

NA 4.95NA

NA NA

NA NA NA NA

14.95

99.95 NA NA

NA

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

TransArmor Data Protection Fee (Flat Rate) $_________ TransArmor Terminal Fee (Flat Rate) $_________

Clover Security Plus Fee (Flat Rate) $_________ PCI Rapid Comply (Flat Rate) $_________

Clover Security Non Clover Fee (Flat Rate) $_________ Clover Security for Clover Fee (Flat Rate) $_________

Clover Security Plus w/o TransArmor Data Protection (Flat Rate) $_________ Clover Service Fee Monthly (per station) (Flat Rate) $_________

Wireless Monthly Service Fee (Per Item) $_________ Wireless Activation Fee (Flat Rate) $_________

Clover Go Monthly Fee (per MID) (Flat Rate) $_________ Clover Insights Fee (per MID) (Flat Rate) $_________

Payeezy Webstore Solution Monthly Fee (per webstore) (Flat Rate) $_________

Perka Solution Monthly Fee (per MID) (Flat Rate) $_________

DCC Chargeback Fee Per Chargeback $_________ DCC Retrieval Fee Per Retrieval $_________ DCC Transaction Fee Per Settlement $_________

Bank Copy - White • Sales Representative Copy - Yellow • Merchant Copy - Pink

Option to purchase: If you wish to buyout the equipment, please contact 1-877-257-2094 to obtain the cost.Address City State Zip Attention:

(w/o taxes, late fees, or other charges that may apply – See Lease Agreement in Program Guide for details. This is a non-cancelable lease for the full term indicated.)

Total Monthly Lease Charge: $__________________ Total Cost To Lease (without tax): $__________________

LEASE COMPANY: (04) First Data Global Leasing Annual Tax Handling Fee:

Lease Term: ______ Mos. ■ AL, AR, CA, CT, GA, IN, KY, LA, MS, MO, NE, NV, NM, ■ All otherNC, OK, OR, RI, SC, TN, Tx, VT, VA, WA, WV, WI, WY ________ States ________30.20 10.20



8. EQUIPMENT/THIRD PARTY INFORMATION

Network (Front End): ■ Omaha ■ North ■ Nashville ■ Buypass

Do you use any third party to store, process or transmit cardholder data? ■ Yes ■ No

If yes, identify the Third Party Processor used: ■ 00 None ■ 01 Yahoo ■ 02 Authorize.net ■ 03 Cybersource ■ 04 Verifone ■ 05 Merchant Link ■ 06 Shift 4

■ 07 Apriva ■ 08 FIS ■ 09 Six Payment Services Corp ■ 10 Verisign ■ 99 Other (please specify) ___________________

INTERNET GATEWAY: ■ First Data Global Gateway ■ Other: ___________________________________________________________________________________________

Wireless Network:__________________________________________________________________________________________________________________________________

PC/Internet Software__________________________________________________________ Quantity _______________ ■ New ■ Rent ■ Lease ■ Existing

Terminal Model_______________________________________________________________ Quantity _______________ ■ New ■ Rent ■ Lease ■ Existing

Printer Model ________________________________________________________________ Quantity _______________ ■ New ■ Rent ■ Lease ■ Existing

PIN Pad _____________________________________________________________________ Quantity _______________ ■ New ■ Rent ■ Lease ■ Existing


Merchant Fee Control Grid Fees (cont’d)

(For the Perka Solution, you will be provided with registration instructions and will beasked to electronically agree to Perka Inc.’s terms and conditions)


N/A

N/A N/A

NA NA

NA NA

NA NA

NA NA

NA NA

19.95 NA

NA

NA

NA

NA NA

✔

Clover Mini WiFi or 3G Clover Flex ✔

Clover Mobile Clover Go Bluetooth ✔

Clover Station Clover Mobile Dock ✔

Clover Mobile Printer

Clover Cash Drawer

Clover Flex Kit

Clover Go Stand


9. SIGNATURE(S)

Client certifies that all information set forth in this completed Merchant Processing Application is true and correct and that Client has received a copy of the Program Guideand Confirmation Page, which is part of this Merchant Processing Application (consisting of Sections 1-9), and by this reference incorporated herein. Client acknowledgesand agrees that we, our Affiliates and our third party subcontractors and/or agents may use automatic telephone dialing systems to contact Client at the telephonenumber(s) Client has provided in this Merchant Processing Application and/or may leave a detailed voice message in the event that Client is unable to be reached, even ifthe number provided is a cellular or wireless number or if Client has previously registered on a Do Not Call list or requested not to be contacted Client for solicitationpurposes. Client hereby consents to receiving commercial electronic mail messages from us, our Affiliates and our third party subcontractors and/or agents from time totime. Client further agrees that Client will not accept more than 20% of its card transactions via mail, telephone or Internet order. However, if your Application is approvedbased upon contrary information stated in Section 8, Transaction Information section above, you are authorized to accept transactions in accordance with the percentagesindicated in that section. This signature page also serves as a signature page to the Equipment Lease Agreement, and the TeleCheck Services Agreement appearing in theThird Party Section of the Program Guide, if selected, the undersigned Client being the “Lessee” for purposes of such Equipment Lease Agreement and/or “You” and “Your”for the purposes of the TeleCheck Services Agreement.

By signing below, each of the undersigned authorizes us, our Affiliates and our third party subcontractors and/or agents to verify the information contained in thisApplication and to request and obtain from any consumer reporting agency and other sources, including bank references, personal and business consumer reports andother information and to disclose such information amongst each other for any purpose permitted by law. If the Application is approved, each of the undersigned alsoauthorizes us, our Affiliates and our third party subcontractors and/or agents to obtain subsequent consumer reports and other infor mation from other sources, includingbank references, in connection with the review, maintenance, updating, renewal or extension of the Agreement or for any other purpose permitted by law and disclose suchinformation amongst each other. Each of the undersigned furthermore agrees that all references, including banks and consumer reporting agencies, may release any andall personal and business credit financial information to us, our Affiliates and our third party subcontractors and/or agents. Each of the undersigned authorizes us, ourAffiliates and our third party subcontractors and/or agents to provide amongst each other the information contained in this Merchant Processing Application and Agreementand any information received subsequent thereto from all references, including banks and consumer reporting agencies for any purpose permitted by law. It is our policyto obtain certain information in order to verify your identity while processing your account application.

As part of our approval, processing services, continuing fraud prevention and account review processes, the undersigned consents to the use of information gatheredonline or that you submit to us, and/or auto mated electronic computer security screening, by us or our third party vendors.

Client authorizes FDMS and Bank and their affiliates to debit Client’s designated bank account via Automated Clearing House (ACH) for costs associated with equipmenthard ware, software and shipping.

You further acknowledge and agree that you will not use your merchant account and/or the Services for illegal transactions, for example, those prohibited by the unlawfulInternet Gambling Enforcement Act, 31 u.S.C. Section 5361 et seq, as may be amended from time to time, or processing and acceptance of transactions in certainjurisdictions pursuant to 31 CFR Part 500 et seq. and other laws enforced by the Office of Foreign Assets Control (OFAC).

Client certifies, under penalties of perjury, that the federal taxpayer identification number and corresponding filing name provided herein are correct.

Client agrees to all the terms of this Merchant Processing Application and Agreement. This Merchant Processing Application and Agreement shall

not take effect until Client has been approved and this Agreement has been accepted by FDMS and Bank.

Client’s Business Principal /Officer:

Signature X _______________________________________________ Title________________________

Print Name of Signer _______________________________________ Date _______________________





TELECHECK ACH AUTHORIZATION

ACH Debit and Credit Authorization: Client authorizes its Financial Institution to pay and charge to its account the amount(s) due TeleCheck under this TeleCheckAgreement and to accept all credits and debits made to its account by TeleCheck via electronic funds transfer in connection with TeleCheck’s services under this TeleCheckAgreement. This authorization shall remain in effect until (30) thirty days after revoked in writing.

Signature X_____________________________________________________ Print Name/Title: _______________________________________________ Date _____________

Authorized Signature on TeleCheck Account for ACH

Personal Guarantee: In exchange for First Data Merchant Services LLC, Wells Fargo Bank, N.A., (a member of Visa uSA, Inc. and MasterCard International, Inc.), andTeleCheck Services, Inc. (the Guaranteed Parties) acceptance of, as applicable, the Agreement, and/or the Equipment Lease Agreement and/or the TeleCheck/TRS ServicesAgreement, the undersigned unconditionally and irrevocably guarantees the full payment and performance of Client’s obligations under the foregoing agreements, asapplicable, as they now exist or as modified from time to time, whether before or after termination or expiration of such agreements and whether or not the undersignedhas received notice of any amendment of such agreements. The undersigned waives notice of default by Client and agrees to indemnify the Guaranteed Parties for any andall amounts due from Client under the foregoing agreements. The Guaranteed Parties shall not be required to first proceed against Client to enforce any remedy beforeproceeding against the undersigned. This is a continuing personal guaranty and shall not be discharged or affected for any reason. The undersigned understands that thisis a Personal Guaranty of payment and not of collection and that the Guaranteed Parties are relying upon this Personal Guaranty in entering into the foregoing agreements,as applicable.

Personal Guarantee Signature X ________________________________________________ Print Name: ___________________________________ Date _____________

Personal Guarantee Signature X ________________________________________________ Print Name: ___________________________________ Date _____________


(Servicers): For First Data Merchant Services LLC

and Wells Fargo Bank, N.A.,

(a member of Visa USA, Inc.

and MasterCard International, Inc.)

X Signature _________________________________________

Clover™, Data Protection and TransArmor® Solution Services Participation Addendum Page 1 of 11

OmahaRCloverDPTA2003(ia)

This Clover, Data Protection and TransArmor Solution Services Participation Addendum (this “Addendum”) executed on ________, 20___,supplements, and is hereby made a part of, the merchant services agreement (the “Agreement”) you (“Client”) have entered into with Processor(the entity named and defined in the signature block below) and Bank or their respective predecessors. Processor and Client hereby agree asfollows:

This Addendum governs the provision of the Clover Service and one or both of the Data Protection Service and/or the TransArmor Solution Services(each as defined below) (collectively, as applicable, the “Service” or “Services”) to you by Processor. By signing below you are electing to receivethe Service and you agree to the applicable terms and conditions set forth in this Addendum. Electing to receive the Clover Service means thatyou shall also elect at least one of either the Data Protection Service or the TransArmor Solution Services for each merchant identification number(“MID”). The Service is provided to you by Processor and not Bank. Bank is not a party to this Addendum, and you acknowledge that Bank is notliable to you in any way with respect to the Service. For the purposes of this Addendum, the words “we,” “our” and “us” refer only to the Processorand not the Bank.

The Service, transactions processed, and other matters contemplated under this Addendum are subject to the terms and conditions of the Agreement,as applicable, except to the extent the terms of this Addendum directly conflict with another provision of the Agreement, in which case the termsof this Addendum will control.

Merchant Address: ___________________________________________________________________________________________

Fax No.: ____________________________________________________________________________________________________

Phone No.: __________________________________________________________________________________________________

Merchant Email (required to receive Clover equipment activation code): ______________________________________________

Partner Email Address: _______________________________________________________________________________________

Merchant DBA: ______________________________________________________________________________________________

Existing MID# (if applicable): ___________________________________________________________________________________

Business URL: ______________________________________________________________________________________________

Menu URL (if applicable): _____________________________________________________________________________________

Clover Service Fees:

Clover Services $___________ (Per Device) x Qty: ______ = $___________ (total per month)

(Charges for Clover Services may appear on your monthly statement or may be billed through the Clover App Market, depending on the device.)

TransArmor Data Protection Service Fees:

� 13 TransArmor Tokenization and Encryption NonClover Fee $___________ (flat rate per month) � Yes � No

� 15 TransArmor Tokenization and Encryption Clover Fee $___________ (flat rate per month) � Yes � No

� 21 TransArmor Essentials Solution NonClover Fee $___________ (flat rate per month) � Yes � No

� 22 TransArmor Essentials Solution for Clover Fee $___________ (flat rate per month) � Yes � No

TransArmor Solution Services Fees:

� 01 TransArmor Solution Services Full Bundle NonClover Fee $___________ (flat rate per month) � Yes � No

� 02 TransArmor Solution Services Full Bundle for Clover Fee $___________ (flat rate per month) � Yes � No

� 03 TransArmor Solution Bundle w/o TransArmor Data Protection $___________ (flat rate per month) � Yes � No

[email protected]

29.95 0.00

0.00


LEASE COMPANY: (04) First Data Global Leasing Lease Term: _________ Months Annual Tax Handling Fee: $______

Monthly Lease Charge for This Location: $_______________ w/o taxes, late fees, or other charges that may apply.

See Lease Agreement for details. This is a NON-CANCELABLE lease for the full term indicated.

10.20

Clover Equipment Details:

The following is for information purposes only. Please refer to your equipment purchase agreement with TASQ Technology, Inc. or your equipmentlease agreement with First Data Global Leasing for information and pricing and fees for your equipment or hardware. You are not purchasing orleasing equipment from Processor and you acknowledge and agree that Processor will have no obligation or liability relating to such purchase orlease or equipment. Your purchase or lease of equipment is subject to separate terms and conditions between you and the equipment seller orlessor.


Network: � Omaha � Nashville

Retail

Purchased Restaurant

Lease Deployment Quick Service(circle one) QTY $ / Unit Fee $ / Unit $ Total Swap Fee* Equipment Type Restaurant

P L ____ $__________ $___________ $___________ $___________ Clover Station (with Cash Drawer) R RE QSR

P L ____ $__________ $___________ $___________ $___________ Clover Station (without Cash Drawer) R RE QSR

P L ____ $__________ $___________ $___________ $___________ Clover Mobile Wi-Fi + 3G R RE QSR

P L ____ $__________ $___________ $___________ $___________ Clover Mini Wi-Fi R RE QSR

P L ____ $__________ $___________ $___________ $___________ Clover Mini Wi-Fi + 3G R RE QSR

P L ____ $__________ $___________ $___________ $___________ Clover Cash Drawer R RE QSR

P L ____ $__________ $___________ $___________ $___________ Clover Weight Scale R RE QSR

P L ____ $__________ $___________ $___________ $___________ Clover Kitchen Printer R RE QSR

P L ____ $__________ $___________ $___________ $___________ Clover Kitchen Printer- Asian Chr R RE QSR

P L ____ $__________ $___________ $___________ $___________ Clover Mobile Printer R RE QSR

P L ____ $__________ $___________ $___________ $___________ Clover Mobile Dock R RE QSR

P L ____ $__________ $___________ $___________ $___________ Clover Bar Code Scanner R RE QSR

P L ____ $__________ $___________ $___________ $___________ Clover Merchant Keypad R RE QSR

P L ____ $__________ $___________ $___________ $___________ Clover Flex R RE QSR

P L ____ $__________ $___________ $___________ $___________ FD40 PIN Pad R RE QSR

Magtek Imagesafe Check Scanner P L ____ $__________ $___________ $___________ $___________ 22370001 (New) R RE QSR

Micrsafe USB Scanner, MSR, Security P L ____ $__________ $___________ $___________ $___________ Level 2, Magensa Key, 22551002-MSR R RE QSR

P L ____ $__________ $___________ $___________ $___________ Restocking Fee (Station/Mobile/Mini/Flex)

P L ____ $__________ $___________ $___________ $___________ Restocking Fee (Peripherals)

P L ____ $__________ $___________ $___________ $___________ Deployment Fee R RE QSR

P L ____ $__________ $___________ $___________ $___________ Injection Fee R RE QSR

*Swap fee applies for a device swap that occurs after the device’s warranty has expired.

X

X

N/A

N/A

0

0

1,499.00 0.00

399.00 0.00

BY SIGNING BELOW, YOU SEPARATELY CONSENT TO THE E-SIGN CONSENT AGREEMENT ABOVE, WHICH YOU ACKNOWLEDGE ISREQUIRED FOR YOUR ACCEPTANCE OF THE CLOVER SERVICE AND PROCESSOR’S ACCEPTANCE OF THIS ADDENDUM.

CLIENT: (“PROCESSOR”)

___________________________________________________ ________________________________________________

By: _______________________________________________ By: ____________________________________________

Title: ______________________________________________ Title: ___________________________________________

GENERAL TERMS

4. FEES.

4.1. Service Fees. You shall pay Processor the fees for Servicesas set forth (a) on the first page above, (b) in the Merchant ProcessingApplication, or (c) in the lease agreement or equipment purchaseagreement, as applicable. Processor may increase your fees for theServices as provided in your Agreement.

4.2. Processing Fees. Processing fees for transactions processedin connection with the use of the Services are the same as for non-Services transactions, which are set forth in the Application.

5. TERM AND TERMINATION.

This Addendum shall become effective on the day we begin providingthe Services to you and shall end when terminated as set forth herein.For the avoidance of doubt, except as set forth below, termination of thisAddendum will not terminate the Agreement. This Addendum may beterminated at any time by either party upon thirty (30) days’ written noticeto the other party. Notwithstanding the foregoing sentence, upon as muchadvance notice as is commercially practicable, we may suspend theServices or terminate this Addendum if (i) we determine that you areusing Services for any fraudulent, illegal, or unauthorized purpose, (ii)you violate the terms of this Addendum or an Event of Default occursunder the Agreement, (iii) we terminate our agreement with any thirdparties that are involved in providing the Services, or (iv) Processorotherwise decides to discontinue providing the Services. Youacknowledge and agree that an occurrence of (i) or (ii) above may bedeemed an Event of Default under the Agreement, thereby affordingProcessor and Bank all rights and remedies as set forth in the Agreementtriggered by such an Event of Default, which may include immediatetermination of the Agreement (and this Addendum) without notice. ThisAddendum will terminate automatically upon the termination of theAgreement.

6. NOTICES.

We may provide notices and other information regarding the Services toyou via the method(s) described in the Agreement or in the E-SignConsent Agreement set forth below.

7. AMENDMENT.

We have the right to change or add to the terms of this Addendum at anytime, and to change, delete, discontinue, or impose conditions on anyfeature or aspect of the Services with notice provided to you as set forthin the Notices section of this Addendum. Any use of the Services afterour publication of any such changes shall constitute your acceptance ofthis Addendum as modified.

8. THIRD PARTY BENEFICIARIES.

Processor’s affiliates and any Persons Processor uses in providing theClover Service are intended third party beneficiaries of this Addendum,and each of them may enforce its provisions as if it was a party hereto.

Except as expressly in this provided in this Addendum, nothing in thisAddendum is intended to confer upon any Persons any rights orremedies, and the parties do not intend for any Persons to be third-partybeneficiaries of this Addendum.

9. RATIFICATION.

The terms of this Addendum shall serve to supplement the terms of yourAgreement. Nothing contained herein alters any existing contractualobligations. Except as expressly set forth herein, the Agreement is herebyratified in all respects and shall remain in full force and effect.

E-SIGN CONSENT AGREEMENT

1. Consent.

By signing this Addendum, you consent and agree that:

a. Processor can provide disclosures required by law and otherinformation about your legal rights and duties to you electronically.

b. Where required or requested, your electronic signature (via “click-through” or other method) on agreements and documents relatingto the Services has the same effect as if you signed them in ink.

c. Processor, its affiliates and its third party subcontractors and/oragents, can send all communications, billing statements,amendments to this Addendum, notices, and other disclosures orinformation regarding the Services or your use of the Service orthe Services as defined herein and in the Agreement (collectivelydefined as “Disclosures”) to you electronically (1) via e-mail, (2)by access to a web site that we designate in an e-mail notice wesend to you at the time the information is available, (3) via SMSand text messages, or (4) to the extent permissible by law, byaccess to a website that we will generally designate in advancefor such purpose.

d. If you want a paper copy, you can print a copy of the Disclosureor download the information for your records.

e. You agree that Processor, its affiliates and its third partysubcontractors and/or agents, may contact you via telephone, liveor artificial, even if the number you provided is a cellular or wirelessnumber or if you have previously registered on a Do Not Call listor requested not to be contacted for solicitation purposes.

f. This consent applies to all future Disclosures sent to you inconnection with this Addendum, the Agreement, or your use of theClover Service or the other Services as defined herein and in theAgreement.

2. Legal Effect. By consenting, you agree that electronic Disclosureshave the same meaning and effect as if Processor provided paperDisclosures to you. When Processor sends you an email or otherelectronic notification alerting you that the Disclosure is availableelectronically and makes it available online, that shall have the samemeaning and effect as if Processor provided a paper Disclosure to you,whether or not you choose to view or print or download the Disclosure.



Clover Go Addendum (New and Existing Merchant / Locations)

Sales Channel: _____________________________________________________________________________________________

Existing MID #: __________________________________ New MID #: _______________________________________________

MID# resides on the following front end: Omaha Nashville

Sales Rep Name: ________________________________ Sales Rep ID: ________________ Phone: _________________________

Partner Email Address: _______________________________________________________________________________________

1. Business Information:

Client’s Business Legal Name: ______________________________________________________________________________

Same as Legal Name or provide:

DBA Name: ____________________________________________ Title: ________________________________________

Your Business Phone:_____________________________ Your Business Fax: ________________________________________

2. Clover Go Service Fees:

$____________

$____________

Clover Go Setup Fe

Clover Go Monthly Fee (per MID)

Clover Go EMV/Chip Reader

Clover Go NFC/EMV/Chip Reader

Clover Go NFC/EMV/Chip Reader Stand

Deployment Fee

$________ per Device x ______ QTY = $ __________

_______ per Device x ______ QTY = $ __________

$________per Device x ______ QTY = $ __________

$________ per Unit x ______ QTY = $ __________

The terms of this Clover Go Addendum (the “Addendum”) shall serve to supplement the terms of your Merchant Processing Application and Agreement (the “Agreement”). By signing below, you acknowledge that you have read, understand and agree to comply with the terms and fees, as set forth in this Addendum. You also understand that the above fees may be modified from time to time in accordance with your Agreement. Except as expressly set forth herein, the Agreement is hereby ratified in all respects and shall remain in full force and effect.

Client’s Business Principal:

Signature (please sign below):

X ______________________________________________ Title: ___________________________ Date: ____________________The party signing this Addendum must be the same party signing the Merchant Processing Application and Agreement.

Print Name of Signer: _________________________________________________________________________________________

CloverGoAdd1911(ia)

NPA 1860/2700 (954) 320-4070

[email protected]

DANIEL FLOORING INC

DANIEL FLOORING

954-583-2233 9549299749

0.00

19.95

0.00 0.00

0.00 0.00

0.00 0.00

0.00 0.00

* Indicates required information

Company Legal Name * "Doing Business As" Name

Company Phone Number * Tax ID Number * Contact Name & Title

Full Mailing Address (physical location, not a PO box) *

Business Type (Corp., Proprietorship, Partnership, LLC, Non-Profit, etc.) Fax Number Email Address

Authorization

Sign Below * Print * Title * Date *

Name #1 * Social Security Number * Date of Birth *

Home Street Address (no PO boxes) *


Name #2 * Social Security Number * Date of Birth *

Home Street Address (no PO boxes) *


Please eMail this application to lisa.o'[email protected]

By signing below, you consent to the investigation of your credit in conjunction with this application. You agree to provide financial statements,

tax returns, etc., as we deem necessary to review this application. You warrant that the information submitted to us is true and correct. You

further hereby authorize us to perform any other type(s) of background checks we deem necessary. The foregoing applies during the term of any

resulting business arrangement between us and you (“Arrangement”) and such investigations, information, reports, and background checks may be obtained by us from time to time during such Arrangement.

Personal Guarantor Information (Complete if the credit application is being submitted with a proposed personal guaranty)

You consent to the investigation of your credit in conjunction with this application. You agree to provide financial statements, tax returns, etc., as we deem necessary to

review this application. You warrant that the information submitted to us is true and correct. You hereby authorize us to obtain further information concerning your credit

standing from any credit bureau, your references, or any other person and that such information and reports may be shared by us with and amongst our affiliates. You

further hereby authorize us to perform any other type(s) of background checks we deem necessary. The foregoing applies during the term of any resulting business

arrangement between us and you (“Arrangement”) and such investigations, information, reports, and background checks may be obtained by us from time to time during such Arrangement.

EQUAL CREDIT OPPORTUNITY ACT NOTICE: If your application for business credit is denied, you have a right to a written statement of the specific reasons for the

denial. To obtain the statement, please contact Credit Disclosure Administrator at CIT Bank, N.A. within 60 days from the date you are notified of our decision. Our mailing

address is 10201 Centurion Parkway North, Suite 100, Jacksonville, FL 32256. Our phone no. is 904-380-9283. We will send you a written statement of reasons for denial

within 30 days of receiving your request for the statement. The federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the

basis of race, color, religion, national origin, gender, marital status, age (provided the applicant has the capacity to enter into a binding contract); because all or part of the

applicant's income derives from any public assistance program; or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act.

The federal agency that administers compliance with this law concerning this creditor is the Bureau of Consumer Financial Protection, 1700 G Street NW, Washington DC

20006

Credit Application

Corp✔ Proprietorship Partnership LLC

X

X

X

EFLLC200 rev 11-2016 Page 1 of 2

Lease Agreement Number: _________

Lease AgreementThis Lease Agreement (the “Lease”) contains the terms of your agreement with us. Please read it carefully and ask us any questions you may have. The words you, your and lessee mean you, our customer. The words we, us, our and the lessor, mean CIT Bank, N.A.

Product Description Quantity Asset Description Product Address

For additional equipment and accessories, attach addendum.

Supplier Info (Name, Address, Phone):

End of Lease Purchase Option If no box is checked or if more than one box is checked, the Fair Market Value Purchase Option will apply.

Fair Market Value $1.00 Purchase Option Other

Term and LeaseLease Payment $ (Plus taxes, if applicable) Term (Months) Payment Frequency MONTHLY

Variable Payment Schedule if applicable: (Attach “Payment Schedule Addendum” if necessary)

payments @ followed payments @ ;

payments @ ; followed by by payments @ ; followed by followed by @

Payments are due in Advance, Net 30 days from Commencement

The following additional payments are due on the date you sign this agreement:

One-time Documentation Fee $0.00 Payable with First Invoice Advanced Payment $0.00 due at Le

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