Instructions for Completing Merchant Processing Forms

PLEASE NOTE: Some of the information contained on these forms is PaymentBanc contact

information. This merchant account will be used solely by PaymentBanc to process your credit card

payments that are under our management. We will be the contact point for this merchant account and

all charges related to it. Therefore you will see some fields that contain PaymentBanc contact

information. That just means that if questions arise, PaymentBanc will be called and your office will

not have to handle the call.

►► Indicates sections where you need to complete information or sign.

Page 1 – Merchant Processing Application and Agreement

Only Section 1, part of Section 4 and 5 require completion. Please do not change any other

information on Page 1. Default values are specific to PaymentBanc.

►► Section 1

Complete ONLY the following information:

Client (Business LEGAL Name)

First / Last Contact Name

Address

►►

►►

Section 4

Please enter the state and year your business started and mark the business type. (Sole

Ownership, Partnership, etc…). Complete the Name as it appears on your income tax return

section and enter the Federal Tax ID #.

Section 5

Important. Please complete this section by supplying the business owner’s information. This

information is required for compliance with the Patriot Act.

Page 2 – (No Action/Changes Needed)

Page 3 – (No Action/Changes Needed)

Page 4 – (No Action/Changes Needed)

Page 5 – (No Action/Changes Needed)

Page 6

Only Section 12 requires completion.

►► Section 12

Please sign at Client’s Business Principal line and complete the Name, Title, and Date.

Section 13 and 14 - Not applicable - Do not sign!

►►

Page 7 - About Merchant’s Business – No Action/Changes Needed

Page 8 - Confirmation Page

►►

Please sign at Client’s Business Principal line and complete the Name, Title, and Date.

Page 9 - Deposit Authorization (Attachment A)

►►

Please sign at the Merchant Name line and complete the Merchant Name, Title, and Date.

Page 10 – Merchant Services Agreement for SUB-MERCHANTS

►►

Please enter in Merchant Name.

Page 11

Please enter in Merchant Name, Name, Title, Date, and Address. Please sign at Signature

►►

line.

Please fax all pages to (888) 758-0587.

Client (Your Business LEGAL Name): Store #:

� Same as Legal Name or Provide DBA/Outlet Name: First /Last Contact Name:

(No P.O. Box) Address: Suite #: City: State: Zip Code:

Your Business Phone: ��Same as Business Phone or Merchant’s Customer Service Phone:

Your Fax Phone: Select One for Retrieval Requests:

�� (02) Dedicated 24 Hour Fax � (03) No fax; mail � (05) eIDs

Your E-Mail Address (Required) : Your Customer Service E-Mail Address:

Website Address:

( 4 ) PROV ID E MORE BU S INE S S DATAState Month/Yr. Incorp. ___ ___ Started: __________ � Sole Ownership � Partnership � Non Profit/Tax Exempt � Public Corp. � Private Corp. � L.L.C. � Gov’t. � Federally Insured

Check one: TIN Type: ��EIN (Fed Tax ID #) � SSN D&B #: ____________________________ No. of Employees: _________

Mag Swipe ______ % + Keyed Manually ______ % = 100% Product/Services You Sell: ________________________________________________________________________

POS Card Present (MAG Swipe and/or Manual Imprint) ______ % + Mail Order/Direct Marketing ______ % + Phone Order ______ % + Internet ______ % = 100%

Do you use any third party to store, process or transmit cardholder data? � Yes ��No (Examples include, but not limited to web hosting companies, Electronic Data Capture, Loyalty programs)

If yes, give name/address: ____________________________________________________________________________________________________________________________

Please identify any Software used for storing, transmitting, or processing Card Transactions or Authorization Requests: _____________________________________________

Client Initials_________

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.)

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

Merchant #: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ Loc. ______ of ______

TeleCheck Subscriber #: ___ ___ ___ ___ ___ ___ ___ ___ Add’l TeleCheck Product Subscriber #: ___ ___ ___ ___ ___ ___ ___ ___

1

MERCHANT PROCESSING APPLICATION AND AGREEMENT (Page 1 of 6)

COMP L ET E S E CT IONS ( 1 - 14 )STMS(TCK)1505 OrthoPB1511(ia)

( 1 ) T E L L U S ABOUT YOUR BU S INE S S

Your Total Cash and Credit Sales: (For All Outlets) $_____________,000Total Annual MC/Visa Volume: (For All Outlets) $_____________,000Total Annual Discover Network Volume: (For All Outlets) $_____________,000Total Annual American Express Volume:(For All Outlets) $_____________,000

TeleCheck Annual Revenue: $_____________,000

( 2 ) MC / V I SA / D I S COVER ® NETWORK / AMER I CAN EXPRE S S ® / T E L ECHECK

Estimated MC/Visa Average Ticket / Sales Amount: $_____________

Estimated Discover Network Average Ticket for this Outlet: $_____________

Estimated American Express Average Ticket for this Outlet: $_____________

Annual MC/Visa Volume for this Outlet: (For Multiple Outlets Only) $_____________,000

Est. Discover Network Annual Sales Volume for this Outlet: (For Multiple Outlets Only) $_____________,000

Est. American Express Annual Sales Volume for this Outlet: (For Multiple Outlets Only) $_____________,000

Highest Ticket Amount: $_____________

Owner/Partner /Officer Name D.O.B. Social Security # Home Phone % of Ownership

Home Address City State Zip Country

Owner/Partner /Officer Name D.O.B. Social Security # Home Phone % of Ownership

Home Address City State Zip Country

( 5 ) PROV ID E YOUR OWNER IN FORMAT ION

PB-

(888) 758 - 0585

(423) 242-2751

0 50 50 0

0 100

( 3 ) ENT I T L EMENT S

��MC /Visa ��Discover Network Full Processing

� Voyager Fleet* Annual Voyager Volume: $______________ *Participation in Voyager Tax Exempt Program: � Yes � No (if yes, additional request form required)

� WEX Full Acquiring Annual WEX Volume: $______________ � WEX (Non-Full Svc) � MC Fleet

� American Express ESA / Pass Through: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ or � Existing SE #: ___ ___ ___ ___ ___ ___ ___ ___ ___

� American Express Cap #: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ Franchise Name: ____________________________________________________________________

Check one for ESA/Pass Through: � Split Dial � Single Settle � EDC � PIP � Reverse PIP

� Debit Package: ___ ___ ___ ___ ___ ___ ___ ___ � EBT FNS # (XREF): ___ ___ ___ ___ ___ ___ ___ SNAP #: ___ ___ ___ ___ ___ ___ ___0 6 6 6 0 0 0 4

9 9 9 9 9 9 9 9 9 9

NOTE: Any Special Instructions must be included on About Merchant’s Business Page.

MERCHANT PROCESSING APPLICATION AND AGREEMENT (Page 2 of 6)

DBA Name: ________________________________________________________________________________ Loc. ______ of ______

Client Initials_________

( 6 ) D E SCR I B E EQU I PMENT D ETA I L S

Network: � (206) CARDnet ® � (4018) Nashville � (4006) Buypass ��Other Specify Security Code: ( )

STMS(TCK)1505 OrthoPBCorpFee1511(ia)

Installation/ � MAG /MIG to Train � Sales Rep. to Train (Receive training via phone, 1-800-558-7101 Opt. #1, M-F 8:00 am -10:00 pm EST & Sat. 10:00 am - 2:00 pm EST)Training: ��No Merchant Training � Installer / In-House (Check training via phone, 1-800-366-1054, M-F 8:00 am -10:00 pm EST & Sat. 10:00 am - 2:00 pm EST)

First/Last Contact Name: ____________________________________________________ Contact Phone #: ______________________ Best Time To Call ________ � am � pm

Imprinter Purchase: � Yes ��No If Yes $_______ x Qty: _______ = $_____________ (w/o Tax) Wireless Provider: � GPRS Cingular or � Other: _____________________

Check one: � Gateway Solutions � Dial Solutions � First Data Global Gateway (FDGG) � VSAT*** � Frame � Other:______________ � IC Verify Serial #_____________

VAR/ Internet / Software: Name: ___________________________________ (Nashville Only: Product ID # ______________________ Vendor ID #______________________ )

NOTE: ***Requires separate agreement between VSAT Provider prior to implementation of this telecommunications protocol.

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 Multiple Locations form for the Monthly Lease Charge for each individual location. See Lease Agreement for details. This is a NON-CANCELABLE lease for the full term indicated. Client Initials: ___________

10.20

( 7 ) F LAT RATE / I C P LU S / T I ER PR I C ING S CHEDUL E

Billed Monthly Fees (If Applicable)

Monthly Service Charge (335) $_________

Minimum Processing Fee (954) $_________

Wireless Access Fee (399)FEE PER TID # OF TIDs TOTAL

$________ x ________ = $_________

ClientLine®/Merchant Insider/EIDS (32R) $_________

Gift Card Monthly Fee (32M) $_________

Payment Essentials Svc. Pkg. (30O) $_________

Web.com Monthly Fee (B28) $_________

TransArmor Monthly Fee (4TA) $_________

Statement Delivery� Electronic (Default) $_________

� Paper Fee (Per Outlet) (240) $_________

Premium Equipment Service Program:

� Yes � No (per location) (32U) $_________

Other: ____________________ $_________

Start-Up Fees (One-Time Charge)

Non-Taxable Fees:Application Fee (Non-Refundable) (32I) $_________

Reprogramming Fee (31A) $_________

Debit Set-up Fee (31B) $_________

Miscellaneous Fee (31J) $_________

*Equipment Purchase (ACH) $______________

Other: _________________ ( ) $_________

Total Amount $________________ w/o tax________________

0.000.00

0.000.000.000.000.000.00

0.00 0.00

0.000.00

0.000.000.000.000.000.00

0.00

0.00

0.000.000.00

*You will be charged the applicable State/City/LocalSales Tax.

Compliance Service Fees

� Annual Fee (32Q) $________or

� Quarterly Fee (33R) $________

0.00

0.00

InternetStart-Up FeesInternet Set-up Fee (30R)FEE PER TID # OF TIDs TOTAL

$________ x ________ = $_________

Billed Monthly FeesFDGG (31Z)FEE PER TID # OF TIDs TOTAL

$________ x ________ = $_________

Internet Service Fee (394)FEE PER TID # OF TIDs TOTAL

$________ x ________ = $________

Global ePricing MC/Visa Service Fee (897, 898) ________%NOTE: Client shall be subject to any foreign currency exposure in connection with Global ePricing transactions.

Trans /Other FeesInternet /FDGG, MC, V, Amex, Dis, Check (03R, 04R, 06I, 07I, 435, L19) $_________

EntitlementsAUTHORIZATION

American Express ESA / Pass Through (10P) $_________

Fraud Flex DetectBase Level OfferingSetup Fee (L32) $_________

Monthly Fee (35A) $_________

Transaction Fee (L35) $_________

0.00

0.000.000.00

0.00

0.00

0.00

0.00

0.00

WEX Full Acquiring Fees

WEX Auth Fee (0D4) $________

WEX Sales Discount (840) ________%

WEX Refund Discount (841) ________%

WEX ChargebackDiscount (842) ________%

WEX ChargebackReversal Disc’t (843) ________%

WEX Chargeback Fee (29H) $________

WEX Retrieval Fee (29I) $________

Buypass FeesDatawire Micronode � Yes � No

Datawire Micronode Monthly Fee (354) $_________

(each)

Authorization Fees

Voyager (0D0,0D1,0DV) $_________

WEX (Non-Full Svc)(0B0, 0B1, 0BV) $_________

Other Payment Fees

Voyager:Sales Discount Rate (844) _________%

Credit Discount Rate (845) _________%

0.00

0.00

0.00

0.00

0.00

Other Payment FeesAmerican Express ESA/Pass Through Fees:*

**Amex Discount Rate: _________% � Amex Monthly Fee:*** $_________

Amex Transaction Fee: $_________(Flat Fee)

*Billed separately by American Express.**Retail & Restaurant merchants will be charged an additional 0.30% for

non-swiped American Express transactions.***Amex Monthly Flat Fee or Discount Rate may apply. Additional .40% applies for any Charge on a Card issued outside the U.S.except MCC 7032, 8211, 8220, and 8351 and Non U.S. Prepaid/Gift cardtransactions.

0.00

Other FeesChargeback Fee

(205, 725, 20L) $_________

MC Cross BorderFee USD (605) _________%

Visa Int’l Svc. Fee (22A) _________%

MC /V/Discover Network/American Express® VoiceAuth (10B,10E,10K,10Q) $_________

EBT (18E, 18I, 02X, 18H) $_________

AVS (405, 406, 407, 408) $_________

TransArmor Token& Encryption (12E) $_________

ACH Reject Fee (401) $_________

Discover Network AVS(07A,07B,07C,079) $_________

Batch Settlement Fee (227) $_________

MC/V/Discover Access Fee (505, 504, 526) $_________

Discover Int’l Svc. Fee (22H) _________%

Discover Int’l Proc. Fee (22G) _________%

Visa Zero $ Verification (10Y) $_________

Visa Misuse of Auth (04G) $_________

Visa Zero Floor Limit (04I) $_________

Partial Auth Non-Participation Fee (12D) $_________

MC Processing Integrity Fee (04F) $_________

MC US Acct Status Inq Svc Interregional Fee (11G) $_________

MC US Acct Status Inq Svc Intraregional Fee (11H) $_________

Other: _________________ $_________

0.00

0.000.00

0.000.000.00

0.000.00

0.00

0.00

0.000.000.000.000.000.00

0.00

0.00

0.00

0.000.00

Note: See Part IV “Additional Important Information Page for Card Processing” in Section A.3

for early termination fees.

0.00

0.00

0.00

0.00

0.00

0.00

0.00

Debit FeesPIN Debit Trans Fee

(018, Key 0-590, Key 0-593) $_________(plus the applicable Network Fees)

– OR –Bundled Debit(PIN, V/MC/Disc Non-PIN)Debit Sales Discount (120) _________%

Debit Sales Trans Fee (124) $_________

Debit Returns Trans Fee (125) $_________(includes all applicable Network Fees)

Note: Bundled Debit is not available for IC Plus

Rental • Purchase Retail • Restaurant •MOTO /Internet Unit Price For Customer-OwnedCustomer-Owned Equipment Type Lodging •Supermarket • Car Rental w/o Tax Equipment Lease (circle one) QTY IP (i.e., Terminal /VAR / Internet) Quick Service Restaurant • Petr Model Code and Name and S&H Track / Version/ Serial #

R P C L � R Re MOTO / I L S C QSR P $

R P C L � R Re MOTO / I L S C QSR P $

R P C L � R Re MOTO / I L S C QSR P $

0.000.00

1 Soft Generic PC 0.00

3401

PB- 1

TE L ECHECK B I L L TO IN FORMAT IONYour Head Office/Bill To Name: First /Last Contact Name: Phone Number:

Suite # City: State: Zip: Your Fax Phone:

� TeleCheck Auto Settle Time: ________ hh ET (Must be at least 1 hour after Card Auto Settle Time)

Tina Mead (888) 758 - 0585Address:

2835 Northpoint Blvd Hixson TN 37343 (423) 242-2751

Client Initials_________

( 7 ) F LAT RATE / I C P LU S / T I ER PR I C ING S CHEDUL E (cont’d)

M ERCHANT PROCE S S ING APP L I CAT ION AND AGRE EMENT (Page 3 of 6)

DBA Name: __________________________________________________________ Pricing Type: ___ ___ ___ Loc. ______ of ______InterchangeSchedule Version: ____________________

STMS(TCK)1505 OrthoPBCorpFee1511(ia)

MC/Visa/Discover Network IC Pass ThruYou will be charged the

applicable interchange ratefrom MC (564), Visa (549), orDiscoverNetwork (527) plus aMC Assessment Fee (273) of0.11% [MC Assessment TranAmt >=$1K (237), an additional0.02% will be charged per MCsettled credit card sale whenthe transaction amount equals$1,000 or greater], a VisaAssess ment Fee (274) of

0.11%, or a Discover NetworkAssessment Fee (234) of0.105%, plus any other feesindicated on this Service Fee

Schedule.

MC/V/ Discover Network Qual Credit Trans Fee (001,002,005,006) (015,016) $__________

MC/V/ Discover Network Qual Non-PIN Debit Trans Fee (130,131,134,135) (787,788) $__________

MC/V/ Discover Network Mid-Qual Credit Trans Fee (611,612,615,616) (717, 718) $__________

MC/V/ Discover Network Mid-Qual Non-PIN Debit Trans Fee (140,141,144,145) (791,792) $__________

MC/V/ Discover Network Non-Qual Credit Trans Fee (621,622,625,626) (721,722) $__________

MC/V/ Discover Network Non-Qual Non-PINDebit Trans Fee (150,151,154,155) (795,796) $__________

0.00

*

*

*

*

( 8 ) T E L ECHECK RATE S , S ERV I C E F E E S , AND S E T UP IN FORMAT ION

TE L ECHECK BANK ING IN FORMAT ION

Funding: � Per Bill To � Per Location

ABA Transit #: ___ ___ ___ ___ ___ ___ ___ ___ ___ Account #: ___________________________________

� Same as above or � Same as above or

ABA Transit #: ___ ___ ___ ___ ___ ___ ___ ___ ___ Account #: ___________________________________

Special Instructions which are part of this Agreement: ________________________________________________________________________________________________________

Please note on separate funding check the designated TeleCheck Service. A separate funding check for TeleCheck Services is NOT required UNLESSMerchant will be using different banking account(s) for TeleCheck Services.

ACH Credits to TeleCheckby Subscriber (For Invoice Payment):

Debits/Credits (Settlement) to Subscriberby TeleCheck and/or Franking Information:

TE L ECHECK R E PORT IN FORMAT ION

Funding Report: � Bill To � Location Delivery Method: � E-Mail � Fax � US Mail Existing Subscriber No.: ___ ___ ___ ___ ___ ___ ___ ___

Contact Name: ___________________________________________________________ Contact Telephone #: ______________________________________________________

Report Fax #: ____________________________________________________________ Report E-Mail Address: ____________________________________________________

Batch Closing Options: _________ � am � pm Format: � CSV (E-Mail only) � PDF

0 0 3PB-

**Retail and Restaurant merchants will be charged an additional 0.30% for non-swiped American Express transactions.Additional .40% applies for any Charge on a Card issued outside the U.S. except MCC 7032, 8211, 8220, and 8351 and Non U.S. Prepaid/Gift card transactions.Gift Card /Prepaid card transactions 1.95% or Supermarket Prepaid fee .20 / transaction.

Discount Fees (Based On Gross Transaction Volume)

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

MasterCard Acceptance Visa Acceptance Discover Network Acceptance

� Accept MC Credit transactions only � Accept Visa Credit transactions only � Accept Discover Network Credit transactions only

� Accept MC Non-PIN Debit trans. only � Accept Visa Non-PIN Debit trans. only � Accept Discover Network Non-PIN Debit trans. only

See Section 1.9 of the Program Guide for details regarding limited accept ance. You are respon sible for dis tin guish ing Credit from Non-PIN DebitCards. Even if you have agreed to limit your accept ance of certain cards as outlined above, you must con tinue to accept all foreign issuedcards, whether Credit or Non-PIN Debit. If you agree to limit your acceptance to a partic ular type of card and, whether intentionally or in error,accept another type of trans action, the resulting transaction will down grade to the highest cost interchange plus the applicable Non-QualifiedSur charge (See Section 18.1 of the Program Guide).

MC/Visa/ MC/Visa/ Transaction Fees MC/Visa/DiscoverDiscover Discover (Applies to MC/ Visa /Discover Network 2-Tier Network/Network Network and American Express

Pricing Method: (Select One) 2-Tier 3-Tier MC/ Visa /Discover Network 3-Tier ONLY) Discount Rate

QUALIFIED DISCOUNT RATES

MC/Visa/ Discover Network Credit Discount Rate (800, 804, 170) __________% __________% __________% __________%

American Express OnePoint**Credit Discount Rate (Key 0-570) __________%

MC/Visa/ Discover Network Non-PIN Debit Discount Rate (850, 854, 964) __________% __________% __________% __________%

MID-QUALIFIED DISCOUNT RATES (Does not apply to MC / Visa/Discover 2 Tier)

MC/Visa/ Discover Network Credit Discount Rate (810, 814, 990) __________%

MC/Visa/ Discover Network Non-PIN Debit Discount Rate (870, 874, 968) __________%

NON-QUALIFIED DISCOUNT RATES

MC/Visa/ Discover Network Credit Discount Rate (820, 824, 994) __________% __________%

MC/Visa/ Discover Network Non-PIN Debit Discount Rate (880, 864, 978) __________% __________%

* Fees do not apply if Bundled Debit is chosen

MC/V/ Discover Ntwk Auth & Return Trans Fee(10A, 10D) (002, 006) (131, 135) (10J, 016, 788) $__________ $__________

American Express OnePoint Transaction Fee $__________

* Fees do not apply if Bundled Debit is chosen

Non-Qual Surcharge Fee (30D, 20N)(excluding inter change pass-through fees, see Section 18.1)Applies to Non-qualified MC, Visa, Discover Network, __________%Amer. Express Credit, and/or Non-PIN Debit Trans.

1

MERCHANT PROCE S S ING APP L I CAT ION AND AGRE EMENT (Page 4 of 6)

DBA Name: __________________________________________________________ Global Table Fee #: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ Loc. ______ of ______

( 8 ) T E L ECHECK RATE S , S ERV I C E F E E S , AND S E T UP IN FORMAT ION (cont’d)

Client Initials_________

� ECA Verification with TRS � TRS for Warranty (Non-Compliance Items) � TRS Other (including Paper Verification)% of Item Amt. Recovered Retained by TRS: 20% % of Item Amt. Recovered Retained by TRS: 20% % of Item Amt. Recovered Retained by TRS: 20%Amt. of Return Item Fee Retained by TRS: 100% Amt. of Return Item Fee Retained by TRS: 100% Amt. of Return Item Fee Retained by TRS: 100%

NOTE: Stop payment checks due to disputes over goods or services must be returned to Subscriber for resolution. Bank Auth: � Yes � No Remittance Frequency: Monthly

( 9 ) TR S S ERV I C E S AND R ECOVERY RATE

Check TotalWARRANTY � ECA � Lockbox � ICA® � CBPSM � Paper � Cashing � Mail Order � COD Set-Up Fees

Average Check Size $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________

Monthly Check/Call Volume $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________

Inquiry Rate _________% _________% _________% _________% _________% _________% _________% _________%

Transaction Fee $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________

Set-Up Fee ($150 + add’l fee per product) $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________

One Rate $_________ $_________

Monthly Minimum $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________

CROC / Voice Auth Fee $_________ $_________ $_________ $_________ $_________ $_________

Statement Processing Fee $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________

December Risk Surcharge _________% _________% _________% _________% _________% _________% _________% _________%

Warranty Maximum$_________ $_________ $_________ $_________ $_________

� Face Amt. � Face Amt. $_________ $_________ � Face Amt. � Face Amt. � Face Amt.

Order Confirmation Notice $_________

TRS Collections � TRS

� TRS� TRS � TRS � TRS � TRS � TRS � TRS

(see TRS Services Section 9) Paper Only

Other: _____________________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________

See TeleCheck / TRS Agreement for definitions, warranties, and any additional fees.Note: See Section 1.38 “Damages” of the TeleCheck / TRS Agreement for early termination fees/ liquidated damages.

$100 Personal$750 Gov$750 Corp

Lockbox Check TotalVERIFICATION � ECA � Lockbox � Pro21 � ICA® � CBPSM � Paper � Cashing � eDeposit Set-Up Fees

Average Check Size $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________

Monthly Check/Call Volume $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________

Transaction Fee $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________

Set-Up Fee ($150 + add’l fee per product) $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________

One Rate $_________ $_________

Monthly Minimum $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________

CROC / Voice Auth Fee $_________ $_________ $_________ $_________ $_________ $_________

Statement Processing Fee $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________

CK21 Max Dollar Amount $_________ $_________

Order Confirmation Notice $_________

TRS Collections � TRS

� TRS� TRS � TRS � TRS � TRS � TRS � TRS

(see TRS Services Section 9) Paper Only

Other: _____________________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________

STMS(TCK)1505 OrthoPBCorpFee1511(ia)

PB- 8 8 0 0 0 0 0 0 0 1 0 6

TeleCheck Services, Inc.P.O. Box 4514Houston, TX 77210-45141-800-366-1054

Set-Up Fees: No. of Physical Locations: ________ 1st Location: @_______ Add’l Location(s): @__________ Total Set-Up Fee: $___________150.00 100.00 ea.

1

( 1 0 ) PAYMENT E S S ENT IA L S

Payment Essentials Type: _____________________________________________________________________________________________________________________________

� Web.com NOTE: 3 Domain Names are required if website is chosen. (Limit 31 characters per line)

Domain Name #1: ______________________________________________________________________________ Suffix Requested: � .com � .net � .org Pick a Template:

Domain Name #2: ______________________________________________________________________________ Suffix Requested: � .com � .net � .org ____________________

Domain Name #3: ______________________________________________________________________________ Suffix Requested: � .com � .net � .org

� Same as Contact Information in Tell Us About Your Business Section or provide:

First/Last Contact Name Contact Phone Contact E-Mail Address

CUSTOM PRICING SCHEDULEDescription Qty. Seq.Code Per Item Cost TOTAL Description Qty. Seq.Code Per Item Cost TOTAL

Custom Cards Transaction Fee G66-G71

Custom Carriers Color & Image Setup Fee Per Order G33

Gift Card Setup Fee Per Location G34 Graphic Design Assistance G40

TOTAL SETUP COST:

STANDARD PRICING SCHEDULEDescription Qty. Seq.Code Per Item Cost TOTAL Description Qty. Seq.Code Per Item Cost TOTAL

Standard Cards Transaction Fee G66-G71

Standard Carriers Envelopes G74

Gift Card Setup Fee Per Location G34

TOTAL SETUP COST:

GIFT CARD TO GO PRICING SCHEDULEDescription Qty. Seq.Code Per Item Cost TOTAL Description Qty. Seq.Code Per Item Cost TOTAL

Gift Cards To Go Transaction Fee G66-G71

TOTAL SETUP COST:

MERCHANT PROCE S S ING APP L I CAT ION AND AGRE EMENT (Page 5 of 6)

DBA Name: ________________________________________________________________________________ Loc. ______ of ______

Client Initials_________

STMS(TCK)1505 OrthoPBCorpFee1511(ia)

( 11 ) G I F T CARD S E TUP

Payment Essentials Gift Card To Go � 100 Gift Card To Go � 100Standard � 500 Custom � 1000 Standard Order � 250 � 500 � 1000 Custom Order � 1000

MARKETING & PROMOTIONAL MATERIALSSequence Part Sequence Part

Description Code Code Qty. Per Item Cost TOTAL Description Code Code Qty. Per Item Cost TOTAL

Acrylic Stand w/Box G35 MNRQ Single J Hook Rack G42 MNF2Acrylic Stand Table Tentw/o Box G48 MNRP Table Tent Acrylic Stand G48 MNG5Insert Poster Insert Poster Standard G30 MNRR Table Tent Poster G30 MNG6

Insert Poster Custom G61 Welcome Kit G77

Door Decal G36 MNRH

TOTAL COST:

GIFT CARD TO GO & STANDARD DESIGN INFORMATION

FRONT OF CARD LANGUAGE:• Maximum 30 characters per line.• 1 - 4 lines (except for Stripe card design)• Use lower and/or upper case letters & spacing where desired.• Text will be printed on the cards exactly as provided hereunless noted in the Comments section.

� TEXT IN ALL CAPS� Text in Upper and Lower Case

Gift Card To Go & Gift Card To Go & Standard Card Design Code: Standard Card Font Color: Front of Card Font:

L1

L2

L3

L4

CUSTOM CARD DESIGN INFORMATION

� Artwork to be provided in electronic format and compliant with specifications set in Custom Card Artwork Requirements. Send artwork to GiftCardArt@firstdata.com.� Concepts or artwork elements to be provided. Send concepts to GiftCardArt@firstdata.com.

CUSTOM PROOF EXCHANGE

� E-Mail proof. E-Mail address for proof approval: _________________________________________________________________________________________________________

� No E-Mail available. Proof will be sent Next Day Air to Client address. Cost will be passed through to Client.

PB- 1

CLIENT INFORMATION

� Same as Tell Us About Your Business Section or provide:First/Last Contact Name Contact Phone Contact E-Mail Address

� Same as Tell Us About Your Business Section or provide:Shipping Address: City: State: Zip:

� Same as Contact Name or Provide Reporting Contact Name � Same as Contact E-Mail Address or Provide Reporting E-Mail Address

Delivery Method: � Ground � 2nd Day � Next Day Air

( 12 ) AGRE EMENT APPROVALThe statements made in this Merchant Processing Application and Agreement are true. Client acknowledges having received and read a copy of the Interchange Schedule (for card processing ser vices),Program Guide (which includes terms and conditions for each of the services, Operating Procedures, Third Party Agreements and a Confirmation Page), and Merchant Processing Application (consisting ofSections 1-14), as modified from time to time in accordance with the provisions of this Agreement, and agrees to be bound by all provisions as printed therein. Client hereby consents to receiving commercialelectronic mail messages from us or our Affiliates from time to time. Client further agrees that Client will not accept more than 20% of its card transac tions via mail, telephone or Internet order. However, ifyour Application is approved based upon contrary information stated in the Provide More Business Data section above, you are authorized to accept transactions in accordance with the percentages indicatedin that Section. This signature page also serves as the signature page to the Equipment Lease Agree ment, TeleCheck/TRS Services Agreement, and the American Express® Card Acceptance Agreementappearing in the Third Party Section of the Program Guide, if selected, the undersigned Client being the “Lessee” for purposes of such Equip ment Lease Agreement, TeleCheck/TRS Services Agreement,and/or “You” and “Your” for the purposes of the American Express Card Acceptance Agreement.By signing below, I represent that I have read and am authorized to sign and submit this application for the above entity which agrees to be bound by the American Express® Card Acceptance Agreement(“Agreement”), and that all information provided herein is true, complete, and accurate. I authorize First Data Merchant Services Corporation and American Express Travel Related Services Company, Inc. (“AXP”)and AXP’s agents and Affiliates to verify the information in this application and receive and exchange infor mation about me personally, including by request ing reports from consumer reporting agencies, fromtime to time, and disclose such information to their agent, subcontractors, Affiliates and other parties for any purpose permitted by law. I authorize and direct First Data Merchant Services Corporation and AXPand AXP agents and Affiliates to inform me directly, or inform the entity above, about the contents of reports on me that they have requested from consumer report ing agencies. Such information will includethe name and address of the agency furnishing the report. I also authorize AXP to use the reports from consumer reporting agencies for marketing and administrative purposes. I am able to read and under -stand the English language. I understand that upon AXP’s approval of the application, the entity will be provided with the Agreement and materials welcoming it, either to AXP’s program for First Data MerchantServices Corporation to perform services for AXP, or to AXP’s standard Card acceptance program, which has different servicing terms (e.g., different speeds of pay). I understand that if the entity does notqualify for the First Data Merchant Services Corporation servicing program, that the entity may be enrolled in AXP’s standard Card acceptance program, and the entity may terminate the Agreement. By acceptingthe American Express Card for the purchase of goods and/or services, or otherwise indicating its intention to be bound, the entity agrees to be bound by the 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 this Application and to request and obtain fromany consumer reporting agency and other sources, including bank references, personal and business consumer reports and other information and to disclose such information amongst each other for anypurpose permitted by law. If the Application is approved, each of the undersigned also authorizes us, our Affiliates and our third party subcontractors and/or agents to obtain subsequent consumer reportsand other information from other sources, including bank references, in connection with the review, maintenance, updating, renewal or extension of the Agreement or for any other purpose permitted by lawand disclose such information amongst each other. Each of the undersigned furthermore agrees that all references, including banks and consumer reporting agencies, may release any and all personal andbusiness credit financial information to us, our Affiliates and our third party subcontractors and/or agents. Each of the undersigned authorizes us, our Affiliates and our third party subcontractors and/oragents to provide amongst each other the information contained in this Merchant Processing Application and Agreement and any information received subsequent thereto from all references, including banksand consumer reporting agencies for any purpose permitted by law. It is our policy to 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 gathered online or that you submit to us, and/orautomated electronic computer security screening, by us or our third party vendors.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 Unlawful Internet 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 certain jurisdictions pursuant to 31 CFR Part 500 et seq. and other laws enforced by theOffice 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.THIS MERCHANT PROCESSING APPLICATION AND AGREEMENT HAS BEEN EXECUTED ON BEHALF OF AND BY THE AUTHORIZED MANAGEMENT OF CLIENT AS OF THE EFFECTIVE DATE.

Client’s Business Principal: (Please sign below)

XSignature____________________________________________________________________

Print Name __________________________________________________________ Date: ____________

Title: � Pres. � V.P. � Member L.L.C. � Owner � Partner � Other: _______________________

XSignature____________________________________________________________________

Print Name __________________________________________________________ Date: ____________

Title: � Pres. � V.P. � Member L.L.C. � Owner � Partner � Other: _______________________

( 11 ) G I F T CARD S E TUP (cont’d)

MERCHANT PROCESSING APPLICATION AND AGREEMENT (Page 6 of 6)

DBA Name: ________________________________________________________________________________ Loc. ______ of ______

BACK OF CARD LANGUAGE SELECTION

GIFT CARD TO GO BACK OF CARD LANGUAGE Thank you very much for your business. We look forward to seeing you again.

BACK OF CARD LANGUAGE � Thank you very much for your business. We look forward to seeing you again.

� Thank you very much for your business. We look forward to seeing you again.Muchas Gracias por su negocio. Esperamos la oportunidad de servirle nuevamente.

� Blank (except for card number)

CUSTOM CARD ONLY: Please note: It is advised that you seek legal advice for custom back of card language.BACK OF CARD LANGUAGE � YES Custom back of card language is to be forwarded to GiftCardArt@firstdata.com.

Back of card artwork is in grey scale only.If custom card language not provided, standard back of card language will be printed:“Thank you very much for your business. We look forward to seeing you again.”

CARD CARRIER SELECTION

GIFT CARD TO GONote: Gift Card to Go carrier design defaults to J Hook and cannot be changed. J Hook Carrier Design:

STANDARD/CUSTOM CARRIER STYLE � Folding � J Hook � Sleeve Pocket

STANDARD/CUSTOM CARRIER DESIGN � Standard Carrier:Note: Sleeve pocket is not able to be customized. � Custom Carrier to match Standard Card Design Code: ___________

� Custom Carrier – Provide custom artwork to GiftCardArt@firstdata.com.� Envelopes Ordered (G74)

Standard back of card language isavailable on standard or custom cards.

Note: Custom card back of card languageis only available on custom cards.

( 14 ) P ER SONAL GUARANTYIn exchange for SunTrust Merchant Services, LLC, SunTrust Bank, American Express and TeleCheck Services, Inc. (the Guaranteed Parties) acceptance of, as applicable, the Agreement, and/or the EquipmentLease Agreement and/or the American Express Card Acceptance Agreement and/or the TeleCheck/TRS Services Agreement, the undersigned unconditionally and irrevocably guarantees the full payment andperformance of Client’s obligations under the foregoing agreements, as applicable, as they now exist or as modified from time to time, whether before or after termination or expiration of such agreementsand whether or not the undersigned has received notice of any amendment of such agreements. The undersigned waives notice of default by Client and agrees to indemnify the Guaranteed Parties for anyand all amounts due from Client under the foregoing agreements. The Guaranteed Parties shall not be required to first proceed against Client to enforce any remedy before proceeding against the undersigned.This is a continuing personal guaranty and shall not be discharged or affected for any reason. The undersigned understands that this is a Personal Guaranty of payment and not of collection and that theGuaranteed Parties are relying upon this Personal Guaranty in entering into the foregoing agreements, as applicable.

Signature (Please sign below): Signature (Please sign below):

X ____________________________________________________________ , an individual X ____________________________________________________________, an individual

( 13 ) T E L ECHECK ACH AUTHOR IZAT IONACH Debit and Credit Authorization: Client authorizes its Financial Institution to pay and charge to its account by electronic fund transfer the amount due TeleCheck and/or TRS under this Agreement andto accept all credits and debits made to its account by electronic fund transfer as a result of TeleCheck’s and/or TRS’ services. This authorization shall remain in effect until thirty days after revoked in writing.

XSignature ____________________________________________________________ Print Name/Title: ____________________________________________ Date: _____________Authorized Signature on TeleCheck Account for ACH

(PROCESSOR): SunTrust Merchant Services, LLC (BANK): SunTrust Bank

XSignature _____________________________________________________Approved Processor Signature

_________________________________________________ Date: ____________Approved TeleCheck Manager

_________________________________________________ Date: ____________Approved TRS Manager

IF TELECHECK SERVICES HAVE BEEN SELECTED, PLEASE SIGN BELOW:

X Signature _____________________________________________________

STMS(TCK)1505 OrthoPB1511(ia)

PB- 1

C H E C K L I S T I N F O R M AT I O N

Regional Office Received Date: ____________ MCC: ___ ___ ___ ___ Merchant Type: RELM:___________________

Pricing Grid # ______________ � Special Pricing Model � Association Grid ��Linkback # ___ ___ ___ ___ ___ ___ ___ ___ ___ NRPT: ___ ___ ___ NCPT: ___ ___ ___

Sales Support ID: ___ ___ ___ ___ Office Admin.: _____________________________________________ Card Rep. #: ___ ___ ___ ___ TeleCheck Rep. #: ___ ___ ___ ___

Print Sales Rep. Name: ______________________________________________________________ Initial: __________ Sales Lead Tracking #: __________________________HIERARCHY: Referral Partner Lead: � Yes � No If yes,

Bank: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ Agent: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ Partner Name: _________________________________

Corp. : ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ Chain: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ Buypass FIID: ___ ___ ___ ___

C A R D S TAT E M E N T S / N O T I F I C AT I O N S D E L I V E RY M E T H O D

Statement Recap Information: (circle one) 01 = Outlet /DBA 02 = Outlet /Bill To 08 = Recap Only/Bill To 07 = Suppress Stmt (No Stmt) 09 = Recap & Outlet /Bill ToStatement Delivery Method: (check one) ��Electronic (Default) � Print and Mail Statement Type: (check one) ��Detail � Summary

Statement E-Mail Address: (Required) ____________________________________________________________________________________________________________________

Head Office/Bill To Name: First/Last Contact Name:

Address: City: State: Zip: Phone #:

ON YOUR BUSINESS ACCOUNT (circle one)

CHECKING STATEMENT ROLLUP: 0 = Each Transfer 1 = Debit/Credit Grouped (By Category) 2 = Net Transfer Amount Only 3 = Net Transfer EOM Fee Combined

� Visit Not Required (Lic. Professional)1. Zone:

� Business District � Industrial � Residential

2. Location: � Mall � Shopping Area � Isolated� Office � Apartment � Home

� Other: _________________________

3. Seasonal: � No � Yes, Mos. in Operation:______

Mos. Open Between ___________ to ___________

4. External Facility Description (# of Levels/Floors):� 1 � 2-4 � 5-10 � 11 plus

5. Merchant Occupies: � Ground Floor � Other: ___________________

6. Remaining Floor(s) Occupied by: � Residential � Commercial � Combination

7. Advertising Name Displayed: �Window � Door � Store Front

8. Approx. Square Footage: � 0-250 � 251-500 � 501-2,000 � 2,001+

9. # of Registers: _______________

10. Return Policy: � Full Refund � Exchge Only � None

11. Do you have a refund policy for your MC /Visa /Discover® Network /American Express® sales?

� Yes ��No If yes, Check one:

� Exchange � Store Credit � Refund Cardholder

If MC/Visa/Discover Network /American Express Credit, within how many days do you submit credittransactions? � 0-3 � 4-7 � 8-14 � Over 14 days

12. Proper License Visible (Liquor, Tax ID, etc.):

� Yes � No, explain:_________________________

13. Your Previous Processor: _________________________________

14. Your Previous Merchant #: ____________________

15. Check Reason for Changing: � Rate � Service � Terminated

� Other: ___________________________________

16. Do You Have Previous ProcessorMC/Visa/Discover Network/American Express Statements? � Yes ��No

17. Are customers required to leave a deposit?

� Yes ��No If Yes, % of deposit required:_____%

Time Frame for Delivery: _______ Days

Comments to Credit Officer /Other Depository / Primary Savings Account Number and Additional Information (40 Characters):

C L I E N T V I S I TAT I O N

C A R D P R O C E S S I N G I N F O R M AT I O N

1. Processing mode: ��EDC: � Paper Voice � Tape � ECR � Paper Terminal 2. Funding will be processed DAILY via: � ACH ��Bankwire

3. Bank will fund: ��Outlet � Head Office 4. # of Plates: ______ Long ______ Short 5. Fire Safety Act: � Yes � No6. Ship Equipment and Welcome Packet to (check one) : � Outlet � Head Office � Other, give mailing information below ��No Welcome Packet and Supplies � No Welcome Packet

Name: First/Last Contact Name:

Address: City: State: Zip:

7. Debit Bill Payment Transaction Type: � Internet � VRU � Recurring � Call Center Sponsoring Debit Network: � NYCE � Pulse � Star

8. Additional Terminal Features: (Check all that apply to ensure timely terminal programming)

� Auto Settle Time _________ hh ET(military)

� Bar Tab

� Clerk /Server Entry

� Debit Cash Back

Delayed Ship Date: __________________

� Dial Prefix: � Dial 9 � Other: ______

� Dial Suffix: _________

� E-Commerce

� If IP _____________________________(List Current Provider)

� QSR-CR/SMT(Convenience/Small Ticket)

� QSR Print Option

____________________

� Invoice Number

� Multi-Trans (PC/Register/Software only)

� No Server/ Ticket ID

� Remove Room # Prompt

� Remove Ticket # Prompt

� Retail Gas

� Retail With Tip

� Ship Method (Overnight)

� Tip % Option

� Verify Amount Prompt

� Partial Approval

� Purchase w/Balance Return

� Standalone Balance Inquiry

� Amex Prepaid ProgramPreference (Choose One)

� Partial Auth

� Balance Back

� Other _____________

PINPad:

� DES Encryption

� DUKPT

� Access Code

#____________________

Terminal Features: (cont'd)

Key PasswordDisable or Protect

Credits � �

Voids � �

Forces � �

Reviews � �

Bal/Settle � �

Auth Only � �

Reports � �

Tip Adjustment � �

Comments:_________________________________________________________________________________________________________________________________________(NOTE: Completing the Comments field will result in a 48 hour terminal programming delay)

C A R D B A N K I N G I N F O R M AT I O N

First /Last Contact Name: Phone #:

ABA #: _________________________________________________________________ DDA #: _________________________________________________________________

� ATTACH A COPY OF FUNDING CHECK.

A B O U T M E R C H A N T ’ S B U S I N E S S

Bank Code: ___ ___ ___ Merchant ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ Buypass Merchant #: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

� TR � TU

DBANAME � � � ��������� � � � � � � � � � � � �Area #: ___ ___ Group #: ___ ___ Service By Region: ___ ___ ___ ___ District Code: ___ ___ ___ ___ ___ ISR Rep ID: ___ ___ ___ ___ SIC # ___ ___ ___ ___

Check Assoc. Code: ___ ___ ___ /____________________________________ Current Check Vendor: ____________________________________________________________

(24 characters)

2 2 1

3 8 0 1 4 0 0 0 0 7 4 0

P B -

Bill Holt (888) 758 - 0585

. 0 1 . 0 10 7 4 0 RSA

RSA00022

Laurie WooleyM O W E

2 2 1 9 6 0 0 2 8 9 9 32 2 1 9 9 0 0 0 2 9 9 2 2 2 1 9 7 0 1 0 5 9 9 7

B N 2 D2 2 1 0 0 0 0 0 1

TMead@orthobanc.com

Tina Mead

2835 Northpoint Blvd Hixson TN 37343

OrthoPB1410(ia)

C O N F I R M A T I O N P A G E STMS1008

Please read the Merchant Processing 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 us. The following information summarizes

portions of your Agreement in order to assist you in answering some of the questions we are most commonly asked:

10. Visa and MasterCard Disclosure

Member Bank Information: Sun Trust Bank

The Bank’s mailing address is Code - FL.-Orlando 9126,7455 Chancellor Drive, Orlando, FL. 38209

and it’s phone number is

Important Member Bank Responsibilities: Important Merchant 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 Merchant

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.

1. Your discount rates are assessed on transactions that qualify for

certain reduced interchange rates imposed by MasterCard and Visa.

Any transactions that fail to qualify for these reduced rates will be

charged an additional fee (see Section 18).

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 notify us

within 45 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 20.

6. 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 23, Term; Events

of Default and Section 24, Reserve Account; Security Interest),

under certain circumstances.

7. By executing this Agreement with us you are authorizing us to

obtain financial and credit information regarding your business and

the signer of the Agreement throughout the term of the Agreement

until all your obligations to us are satisfied.

8. The Agreement contains a provision that in the event you

terminate the Agreement early, you will be responsible for the

payment of an early termination fee as set forth in Section 38 under

“Additional Fee Information.”

9. If you lease equipment from Processor, it is important that you

review section 37. This lease is a non-cancelable lease for the full

term indicated.

(a) Ensure compliance with cardholder data security and storage

requirements.

(b) Maintain fraud and chargebacks below Association thresholds.

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

(d) Comply with Visa and MasterCard rules.

Print Client’s Business Legal Name: _______________________________________________________________________________

By its signature below, Client acknowledges that it has received the Interchange Qualification Matrix (version IQMMVDiscS.06.1 or

version IQMMVDiscS.07.1) and complete Program Guide ( STMS10098 )

Consisting of 44 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’s Business Principal:

Signature (Please sign below):

X_____________________________________________________ ___________________________________ _________________

Title Date

_____________________________________________________

Please Print Name of Signer

Attachment A

DEPOSIT AUTHORIZATION

Whereas Sun Trust Merchant Services, LLC and Sun Trust Bank (Servicers) have entered into a Merchant Processing Agreement

(Agreement) with the undersigned Merchant (Merchant) to provide processing Services (as that term is defined in the Agreement);

Whereas Merchant has authorized Servicers to debit via ACH transfer all fees and other amounts owing pursuant to the Agreement

from the Settlement Account designated in the Agreement;

Whereas, Merchant has entered into an agreement with OrthoBanc, LLC for the management of payments made to Merchant for

accounts designated to OrthoBanc, LLC by Merchant, including but not limited to the management of failed or missed payments to

Merchant that may occur;

Whereas, notwithstanding the designation of the Settlement Account for the debiting of fees as referenced above, Merchant desires

that its transaction deposits pursuant to the Agreement be deposited into a bank account designated by OrthoBanc, LLC;

NOW, THEREFORE, by their signatures below, Merchant and OrthoBanc, LLC agree as follows:

1. Notwithstanding anything to the contrary contained in the Agreement, effective upon the full execution of this Deposit

Authorization, all amounts to be paid to Merchant pursuant to the Agreement shall be deposited via ACH transfer into a

“Settlement Account” designated by OrthoBanc, LLC. I understand that OrthoBanc will provide the Settlement Account

designation to Servicers separately and that such designation may not appear on my Merchant Processing Application.

(a) All payments due Merchant shall be made to the “Settlement Account” designated by OrthoBanc, LLC unless and until

Servicers receive written notification from an authorized representative of Merchant to the contrary. Servicers are not required to alter

their regular course of business with respect to acceptance of payment instructions from Merchant and Servicers shall have no liability

if they act in accordance with payment instructions received from an employee or agent of the Merchant acting with apparent

authority. Servicers shall incur no liability for changes or modifications made to the amounts forwarded to OrthoBanc, LLC pursuant

to instructions received from OrthoBanc, LLC or Merchant. Merchant and/or OrthoBanc, LLC are solely responsible for contacting

the bank referenced in paragraph 1 above and notifying them of the ACH deposits to be sent by Servicers in the name of Merchant.

Servicers are not responsible for any reject of said ACH deposits by said bank.

(b) The distribution and/or allocation of any funds deposited pursuant to this Authorization is solely between Merchant and

OrthoBanc, LLC. Servicers shall have no responsibility or involvement whatsoever as to how funds deposited into the above

referenced account are dispersed and/or utilized.

2. In addition to depositing the proceeds of credit card submissions, Servicers also utilizes the Settlement Account to fund

debits arising from its processing services for fees, refunds, chargebacks, and other amounts that may be due under the Agreement.

The Merchant and OrthoBanc, LLC hereby authorize Servicers to access the Settlement Account to initiate credit and/or debit entries

by bankwire or ACH transfer to pay any amounts owing by Merchant to Servicers pursuant to the Agreement. This authorization is

without respect to the source of any funds in the Settlement Account. This authority extends to any fees and assessments and

chargeback amounts of whatever kind or nature due to Servicers under the terms of the Agreement whether arising during or after

termination of the Agreement.

3. Pursuant to the agreement between Merchant and OrthoBanc, LLC referenced above, Merchant understands that,

notwithstanding anything in the Agreement to the contrary, amounts charged may be adjusted by OrthoBanc, LLC pursuant to

Merchant’s agreement with OrthoBanc. Servicers are not responsible for the amounts charged by OrthoBanc, LLC to Merchant for its

services or for notices related to said charges.

4. Merchant and OrthoBanc, LLC confirm and agree that: (i) except as otherwise stated herein, the Agreement is in full force

and effect, and (ii) this authorization does not prohibit, limit or alter the rights possessed by Servicers under the Agreement in any

manner whatsoever. OrthoBanc, LLC is not intended as a third party beneficiary of the Agreement between Servicers and Merchant.

5. The Merchant and OrthoBanc, LLC agree to indemnify and hold Servicers harmless for any action taken by Servicers in

accordance with the terms of this authorization.

OrthoBanc, LLC Merchant Name:

By (signature) By (signature)

Print Name Bill Holt Print Name

Title President Title

Dated Dated

10 

MERCHANT SERVICES AGREEMENT for SUB-MERCHANTS

In connection with (“Merchant”) agreement with OrthoBanc, LLC (“Provider”), Vantiv, LLC and its designated Member Bank (collectively “Vantiv”) will provide Merchant with certain payment processing services (“Services”) in accordance with the terms of this Merchant Services Agreement. In consideration of Merchant’s receipt of credit or debit card funded payments, and participation in programs affiliated with MasterCard International Inc. ("MasterCard"), VISA U.S.A. Inc. ("VISA"), Discover (“Discover”), and certain similar entities (collectively, “Associations), Merchant is required to (i) enter into a direct relationship with an entity that is a member of the Associations and (ii) agree to comply with Association rules as they pertain to applicable credit and debit card payments. By executing this Merchant Services Agreement, Merchant is fulfilling the Association rule of entering into a direct relationship with a Member of the Associations; however, Vantiv understands that Merchant may have contracted with Provider to obtain certain processing services and that Provider may have agreed to be responsible to Merchant for all or part of Merchant’s obligations contained herein.

NOW, THEREFORE, in consideration of the foregoing recitals and of the mutual promises contained herein, the parties agree as follows:

1. Certain Merchant Responsibilities.

Merchant agrees to participate, and to cause third parties acting as Merchant’s agent (“Agents”), to participate, in the Associations in compliance with, and subject to, the by-laws, operating regulations and/or all other rules, policies and procedures of the Associations (collectively "Operating Regulations"). Merchant also agrees to comply with all applicable state, federal, and local laws, rules, and regulations (“Laws”). Without limiting the foregoing, Merchant agrees that it will fully comply with any and all confidentiality and security requirements of the USA Patriot Act (or similar law, rule or regulation), VISA, MasterCard, Discover, and/or Other Networks, including but not limited to the Payment Card Industry Data Security Standard, the VISA Cardholder Information Security Program, the MasterCard Site Data Protection Program, and any other program or requirement that may be published and/or mandated by the Associations. For purposes of this section, Agents include, but are not limited to, Merchant’s software providers and/or equipment providers.

If appropriately indicated in Merchant’s agreement with Provider, Merchant may be a limited-acceptance Merchant, which means that Merchant has elected to accept only certain Visa and MasterCard card types (i.e., consumer credit, consumer debit, and commercial cards) and must display appropriate signage to indicate the same. Vantiv has no obligation other than those expressly provided under the Operating Regulations and applicable law as they may relate to limited acceptance. Merchant, and not Vantiv, will be solely responsible for the implementation of its decision for limited acceptance, including but not limited to policing the card type(s) accepted at the point of sale.

Merchant shall only complete sales transactions produced as the direct result of bona fide sales made by Merchant to cardholders, and is expressly prohibited from processing, factoring, laundering, offering, and/or presenting sales transactions which are produced as a result of sales made by any person or entity other than Merchant, or for purposes related to financing terrorist activities.

Merchant may set a minimum transaction amount to accept a card that provides access to a credit account, under the following conditions: i) the minimum transaction amount does not differentiate between card issuers; ii) the minimum transaction amount does not differentiate between MasterCard, Visa, or any other acceptance brand; and iii) the minimum transaction amount does not exceed ten dollars (or any higher amount established by the Federal Reserve). Merchant may set a maximum transaction amount to accept a card that provides access to a credit account, under the following conditions: Merchant is a i) department, agency or instrumentality of the U.S. government; ii) corporation owned or controlled by the U.S. government; or iii) Merchant whose primary business is reflected by one of the following MCCs: 8220, 8244, 8249 –Schools, Trade or Vocational; and the maximum transaction amount does not differentiate between MasterCard, Visa, or any other acceptance brand.

2. Merchant Prohibitions.

Merchant must not i) require a cardholder to complete a postcard or similar device that includes the cardholder’s account number, card expiration date, signature, or any other card account data in plain view when mailed, ii) add any tax to transactions, unless applicable law expressly requires that a Merchant impose a tax (any tax amount, if allowed, must be included in the transaction amount and not collected separately), iii) request or use an account number for any purpose other than as payment for its goods or services, iv) disburse funds in the form of travelers checks if the sole purpose is to allow the cardholder to make a cash purchase of goods or services from Merchant, v) disburse funds in the form of cash unless Merchant is dispensing funds in the form of travelers checks, TravelMoney cards, or foreign currency (in such case, the transaction amount is limited to the value of the travelers checks, TravelMoney cards, or foreign currency, plus any commission or fee charged by the Merchant), or Merchant is participating in a cash back service, vi) submit any transaction receipt for a transaction that was previously charged back to the acquirer and subsequently returned to Merchant, irrespective of cardholder approval, vii) accept a Visa consumer credit card or commercial Visa product issued by a U.S. issuer to collect or refinance an existing debt, viii) accept a card to collect or refinance an existing debit that has been deemed uncollectable by Merchant, or ix) submit a transaction that represents collection of a dishonored check. Merchant further agrees that, under no circumstance, will Merchant store cardholder data in violation of the Laws or the Operating Regulations including but not limited to the storage of track-2 data. Neither Merchant nor its Agent shall retain or store magnetic-stripe data subsequent to the authorization of a sales transaction.

3. Settlement.

Upon receipt of Merchant’s sales data for card transactions through Provider Services, Vantiv will process Merchant’s sales data to facilitate the funds transfer between the various Associations and Merchant. After Vantiv receives credit for such sales data, Vantiv will fund Merchant, either directly to the Merchant-Owned Designated Account or through Provider to an account designated by Provider (“Provider Designated Account”), at Vantiv’s sole option, for such card transactions. Merchant agrees that the deposit of funds to the Provider Designated Account shall discharge Vantiv of its settlement obligation to Merchant, and that any dispute regarding the receipt or amount of settlement shall be between Provider and Merchant. Vantiv will debit the Provider Designated Account for funds owed to Vantiv as a result of the Services provided hereunder, unless a Merchant-owned account is otherwise designated below.

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Further, if a cardholder disputes a transaction, if a transaction is charged back for any reason, or if Vantiv reasonably believes a transaction is unauthorized or otherwise unacceptable, the amount of such transaction may be charged back and debited from Merchant-Owned Designated Account.

4. Term and Termination

This Merchant Services Agreement shall be binding upon Merchant upon Merchant’s execution. The term of this Merchant Services Agreement shall begin, and the terms of the Merchant Services Agreement shall be binding upon Vantiv, on the date Vantiv accepts this Merchant Services Agreement by issuing a merchant identification number, and shall continue until either party gives at least thirty (30) days prior written notice to the other party.

Notwithstanding the foregoing, Vantiv may immediately cease providing Services and/or terminate this Merchant Services Agreement without notice if (i) Merchant or Provider fails to pay any amount to Vantiv when due, (ii) in Vantiv's opinion, provision of a service to Merchant or Provider may be a violation of the Operating Regulations, or any applicable state, federal, or local laws, rules, and regulations (“Laws”), (iii) Vantiv believes that Merchant has violated or is likely to violate the Operating Regulations or the Laws, or iv) Vantiv is required to do so by any of the Associations.

5. Indemnification and Limits of Liability.

Merchant agrees to provide Vantiv with written notice, specifically detailing any alleged failure, within thirty (30) days of the date on which the alleged failure or error first occurred; failure to so provide notice shall be deemed an acceptance by Merchant and a waiver of any and all rights to dispute such failure or error. Vantiv shall bear no liability and have no obligations to correct any errors resulting from Merchant’s failure to comply with the duties and obligations of the preceding sentence

Merchant shall indemnify and hold harmless Vantiv, and its directors, officers, employees, affiliates, and agents from and against all proceedings, claims, demands, losses, liabilities, damages and expenses resulting from or otherwise arising out of (i) the Services in this Merchant Services Agreement, (ii) Merchant’s or Merchant’s employees and agents acts or omissions in connection with the Services provided pursuant to this Merchant Services Agreement, (iii) any infiltration, hack, breach, or violation of the processing system resulting from, arising out of, or in any way related to Merchant’s ability to use of the services provided herein including but not limited to Merchant’s use of an Agent or any other third party processor or system or (iv) any issue between Merchant and Provider. This indemnification shall survive the termination of the Agreement. Vantiv’s liability related to or arising out of this Merchant Services Agreement shall in no event exceed $5,000. Merchant’s sole and exclusive remedy for any and all claims against Vantiv arising out of or in any way related to the transactions contemplated herein shall be termination of this Merchant Services Agreement. Merchant acknowledges that Vantiv is not liable for any action or failure to act by Provider, and that Merchant shall have no liability whatsoever in connection with any products or services provided to Merchant by Provider.

6. Miscellaneous.

This Merchant Services Agreement is entered into, governed by, and construed pursuant to the laws of the State of Ohio without regard to conflicts of law provisions. This Agreement may not be assigned by Merchant without the prior written consent of Vantiv. This Agreement shall be binding upon and inure to the benefit of the parties hereto and their respective successors, transferees and assignees. This Agreement is for the benefit of, and may be enforced only by, Vantiv and Merchant and is not for the benefit of, and may not be enforced by, any other party. Vantiv may amend this Merchant Services Agreement upon notice to Merchant in accordance with Vantiv’s standard operating procedure. If any provision of this Agreement is determined to be illegal or invalid, such illegality or invalidity of that provision will not affect any of the remaining provisions and this Merchant Services Agreement will be construed as if such provision is not contained in the Agreement “Member Bank” as used in this Merchant Services Agreement shall mean a member of VISA, MasterCard and/or Discover, as applicable, that provides sponsorship services in connection with this Merchant Services Agreement. As of the commencement of this Merchant Services Agreement, Member Bank shall be Fifth Third Bank, an Ohio Banking Corporation, located at 38 Fountain Square Plaza, Cincinnati, OH 45263. The Member Bank is a party to this Merchant Services Agreement. The Member Bank may be changed, and its rights and obligations assigned to another party by Vantiv at any time without notice to Merchant.

IN WITNESS WHEREOF, this Merchant Services Agreement has been executed by the parties’ authorized officers as of the dates set forth below.

Merchant:

Signature:

Name:

Title:

Date:

Address:

Provider: OrthoBanc, LLCSignature:

Name: Bill Holt

Title: President

Date:

Address: 2835 Northpoint Blvd

Hixson, TN 37343

Suite:

City: State: Zip: