Page 1 Version 121020 © 2019 Merchant Application

Persons opening an account on the behalf of a legal entity must provide the following information: MERCHANT NAME (DBA OR TRADE NAME) CORPORATE / LEGAL NAME

LOCATION ADDRESS CORPORATE ADDRESS

CITY STATE ZIP CITY STATE ZIP

CONTACT TELEPHONE CONTACT EMAIL ADDRESS CONTACT TELEPHONE FAX NUMBER FEDERAL TAX ID#

YEARS IN BUSINESS

DOES THIS LOCATION CURRENTLY ACCEPT VISA/ MASTERCARD/DISCOVER® NETWORK/AMERICAN EXPRESS®?

AVERAGE TICKET / MAXIMUM TICKET $MONTHLY VOLUME

TYPE OF GOODS OR SERVICES

WEBSITE ADDRESS WWW. NO YES CUSTOMER SERVICE #

CURRENT PROCESSOR

MUST PROVIDE 2 MONTHS PREVIOUS PROCESSOR STMTS

PLEASE CHOOSE MAILING

ADDRESS

DBA

LEGAL

NUMBER OF LOCATIONS

MCC/SIC CODE

OWNERSHIP: MUST PROVIDE DOCUMENTATION

STOCK SYMBOL (if publicly traded)

(a) PRINCIPALS: The following information for each individual, if any, who, directly or indirectly, through any contract, arrangement, understanding, relationship or

otherwise, owns 25 percent or more of the equity interests of the legal entity listed above: (Please provide copy of driver’s license for each signing principal)

1.PRINCIPAL NAME: FIRST MIDDLE LAST SSN % OWNERSHIP TITLE

HOME ADDRESS CITY STATE ZIP

HOME PHONE DRIVERS LICENSE NUMBER / PASSPORT NUMBER & EXP DATE DATE OF BIRTH

2.PRINCIPAL NAME: FIRST MIDDLE LAST SSN % OWNERSHIP TITLE

HOME ADDRESS CITY STATE ZIP

HOME PHONE DRIVERS LICENSE NUMBER / PASSPORT NUMBER & EXP DATE DATE OF BIRTH

PAYMENT CARD INDUSTRY DATA SECURITY STANDARD: MUST PROVIDE COPY OF SELF ASSESSMENT QUESTIONNAIRE. IF APPLICABLE, MUST PROVIDE CERTIFICATE OF COMPLIANCE.

INDIVIDUAL/SOLE PROPRIETORCORPORATIONPARTNERSHIPLLCNON-PROFIT (must provide 501c3 Letter)PA/PC

VISA/MASTERCARD/DISCOVER

$

$

AMERICAN EXPRESS AVERAGE TICKET / MAXIMUM TICKET $ $MONTHLY VOLUME $

BY CHECKING THIS BOX, MERCHANT OPTS OUT OF RECEIVING FUTURE COMMERCIAL MARKETING COMMUNICATIONS FROM AMERICAN EXPRESS

INDICATE VISA, MASTERCARD, DISCOVER, AXP CARD OR PAYPAL TYPES NOT TO ACCEPT

MERCHANT APPLICATION AND AGREEMENT Sales Rep. Name: ___________________________ Sales Office #: ______________________ Merchant # ________________________

348 Hiatt Drive, Suite 205 Palm Beach Gardens, FL, 33418 Tel: (866) 873-2200

Type of Building:

___________________

HAVE MERCHANT OR OWNERS / PRINCIPALS EVER FILED:

BUSINESS BANKRUPTCY

(If yes, please explain)

PERSONAL BANKRUPTCY NEVER FILED

HAVE MERCHANT OR OWNERS / PRINCIPALS EVER BEEN TERMINATED FROM ACCEPTING BANKCARDS FOR THIS BUSINESS OR ANY OTHER BUSINESSES?

NO YES

(If yes, please explain)

InventoryYes _____ No_____

SITE INSPECTION SURVEY

I hereby verify that I have inspected the business premises of the merchant.Yes _____ No_____ Signage

Yes _____ No_____Inspected By Agent x

(b) MANAGEMENT: Complete the following information for one individual with significant responsibility for managing the legal entity listed above, such as - An Executive Officer or Senior Manager (e.g. Chief Operating Officer, Chief Executive Officer, Chief Financial Officer, Managing Member, General Partner, President, Vice President, Treasure): or - Any individual who regularly performs similar functions. If appropriate, an individual listed under section (a) above may also, be listed in this section (b) CHEC BOX if same individual is listed in section (a)____1. PRINCIPAL NAME: FIRST MIDDLE LAST SSN % OWNERSHIP TITLE

HOME PHONE DRIVERS LICENSE NUMBER / PASSPORT NUMBER & EXP DATE DATE OF BIRTH

RETAIL SWIPED KEYED ECOMM MOTO

Page 2 Version 121020

SALES METHOD (MUST EQUAL 100%) %

FEE SCHEDULE

% or Pass Thru I/C Plus ______

% or Pass Thru I/C Plus ______

$0.10

Merchant: Esquire Bank: Print Legal Name of Merchant Business (Signature)

Date: (Name and Title)

Principal 1:

Govt. Compliance Fee $4.95 - Fee TIN Mismatch Fee $35 - Annual Technology Fee $39 - PCI Non-Compliance Fee $29 - ACH Reject Fee $35 - Early Termination Fee $495 - Voice Auth. Fee $1.50 per trans - Annual PCI Fee $99 - Wireless Fee $25 - Warranty Fee $19

MERCHANT ACCEPTANCE AND AGREEMENTBy executing this Merchant Application on behalf of the merchant described above (the “Merchant”), the undersigned individual(s): (i) represent(s) and warrant(s) that all information contained in this Merchant Application Is true, correct and complete as of the date of this Merchant Application, and that such individual(s) have the requisite corporate power and authority to complete and submit this Merchant Application and make and provide the acknowledgements, authorizations and agreements set forth below, both on behalf of theMerchant and individually; (ii) acknowledge(s) that the information contained in this Merchant Application is provided for the purpose of obtaining, or maintaining a merchant account with Bank on behalf of the Merchant; (iii) authorize Bank to investigate the credit of the Merchant and each person listed on this Merchant Application; (iv) agree, on behalf of the Merchant and in the event this Merchant Application is accepted and executed by Bank, to the Fee Schedule set forth above and to the Terms and Conditions included with and incorporated into this Merchant Agreement. Merchant understands that this Agreement shall not take effect until Merchant has been approved by Bank and a merchant number is issued.

PERSONAL GUARANTEE

In consideration of Bank’s acceptance of this Agreement, the undersigned Guarantor (jointly and severally if more than one) unconditionally guarantees the performance of all obligations of Merchant to Bank under the Agreement, and payment of all sums due there under, and in the event of default, hereby waives notice of default and agrees to indemnify Bank for all funds due from Merchant pursuant to the terms of the Agreement. Guarantor waives any and all rights of subrogation, reimbursement or indemnity derived from Merchant, and further waives any and all rights or defenses arising by reason of any modification or change in the terms of the Agreement whatsoever, including, without limitation, the renewal, extension, acceleration, or other change in the time any payment or other performance there under is due, and / or any change in any interest or discount rate or fee there under. Guarantor confirms that Guarantor, collectively or individually, is a party to the Agreement, and unconditionally and specifically authorizes Bank or their authorized agents, to debit any overdue fees, costs, chargebacks, fines, fees, penalties, expenses or obligations under the Agreement and / or any contractual relationship with Bank from any personal checking account or other account owned or controlled by Guarantor, and further to report any default hereunder on Guarantor’s personal Credit Bureau Report. Guarantor agrees to pay all costs and expenses of whatever nature, including attorneys’ fees and other legal expenses, incurred by or on behalf of Bank in connection with the enforcement of this Guaranty.

Guarantor Date

:

______

______

AMEX OPT BLUE Qualified Rate

Mid Qual

Non Qual ______

Pass Thru I/C Plus ______ BP

Amex ESA #__________________

0.40%

______

______

$15.00

AVS TransactionFee

EBT Transaction Fee

EBT Account #

Amex Processing Fee

Equipment Fee

For 3-Tier Pricing:

Visa/MC/Disc/AXP Mid Qual

Visa/MC/Disc/AXP Non Qual

Chargeback Fee

ACH Retrieval Fee $15.00

x

x

x

%

BANK ACCOUNT INFORMATION ROUTING NUMBER

ATTACH VOIDED CHECK

ACCOUNT NUMBER

(Signature of Principal/Owner)

% %

_____

_____

_____

Qualified Credit Card Discount Rate(for Tiered/Flat)

Qualified Check Card Discount Rate(for Tiered/Flat)

Visa/MasterCard/Discover Auth. Fee

AXP Authorization Fee

Monthly Program Fee "Cash Discount" $

Customer Service Fee/Statement

Monthly Minimum Fee

PIN Debit Transaction Fee _____

Batch Fee _____

______

______

______

______

_____

Additional Documents Needed:• Two (2) Months Bank Statements• Driver's License• Two(2) Months Processing Statements• Voided Check

Note: If new franchisee, personal bank statements may be requested as well as personal tax returns.

• W9• Articles of Incorporation or

business license• Merchant Attestation Form Missing informaton may delay the approval process

Page 3 © 2021 Merchant Application

PLEASE DESCRIBE YOUR REFUND / RETURN

POLICY:

BANK DISCLOSURE

Member Bank Information:

Esquire Bank 100 Jericho Quadrangle, Suite 100 Jericho, NY 11753

Important Bank Responsibilities:

Esquire Bank is the only entity approved to extend acceptance of VISA products directly to a Merchant. Esquire Bank must be a principal (signor) to the Merchant Agreement. Esquire Bank is responsible for educating Merchants on pertinent VISA Operating Regulations with which Merchants must comply. Esquire Bank is responsible for and must provide settlement funds to the Merchant. Esquire Bank is responsible for all funds held in reserve that are derived from settlement.

Important Merchant Responsibilities:

Ensure compliance with cardholder data security and storage requirements. Maintain fraud and chargebacks below thresholds. Review and understand the terms of the Merchant Agreement. Comply with VISA Operating Regulations.

The responsibilities listed above do not supersede terms of the Merchant Agreement and are provided to ensure the Merchant understands some important obligations of each party and that the VISA Member—Esquire Bank—is the ultimate authority should the Merchant have any problems.

Merchant’s Signature Date

Merchant’s Printed Name & Title

  VeriFone   PAX   Ingenico   Dejavoo   Terminal Model

______________________

  Pin Pad Model:

___________________

  Ethernet/IP File Required Terminal Auto Close:   Yes   No

Time: ___________ AM ___________ PM

  Gateway _____________________________

Shopping Cart___________________________

Tips: Counter tip RestaurantWireless:

GPRS   CDMA   Multi-Merchant Main MID: _________________

For Mobile Set Up: Model: _________________ Manufacturer__________

EQUIPMENT

Cell Phone #: ______________________

  Software: ______________________________

Software Version: __________________________

  Check Reader Model

________________

  Reprogram   New Equipment

If Phone Code Needed for Dial Out,

Enter Here: __________

Carrier: __________________________

A

DEPLOYMENT SECTION

  VeriFone   PAX   Ingenico   Dejavoo   Terminal Model

______________________

  Pin Pad Model:

___________________

  Ethernet/IP File Required Terminal Auto Close:   Yes   No

Time: ___________ AM ___________ PM

  Gateway _____________________________

Shopping Cart___________________________

Tips: Counter tip RestaurantWireless:

GPRS   CDMA   Multi-Merchant Main MID: _________________

For Mobile Set Up: Model: _________________ Manufacturer__________

EQUIPMENT

Cell Phone #: ______________________

  Software: ______________________________

Software Version: __________________________

  Check Reader Model

________________

  Reprogram   New Equipment

If Phone Code Needed for Dial Out,

Enter Here: __________

Carrier: __________________________

Ship Terminal to Agent Ship Terminal to Merchant In Person Install- MLS

   NNo o

   VVerieriFFoonne e    PPAAXX    IIngengenniico co    DejDejaavoovoo    TTererminalminal MoModdel el

____________________________________________

   PPiin n PPadad MMododelel::

______________________________________

   EEtthherernnetet//IIPP FFiille e ReqRequuiirreded TTerermmiinanall AAututoo CCllose:ose:    YYees s

TTiimme:e: _____________________ _ AAM M ______________________ PPMM

   GGatateweway ay __________________________________________________________

SShohoppippinng g CarCartt____________________________________________________ __

TTips:ips: Counter Counter tip tip RestaurantRestaurantWWirireellesess:s:

GGPPRSRS    CDMCDMAA    MuMullttii--MeMerrchchanantt MaMaiin n MMIID:D: __________________________________

FFoorr MoMobbiille e SSeett UUpp:: MMododelel:: __________________________________ MMananufufacactturureerr____________________

EEQUQUIIPPMEMENNTT

CellCell PPhohone ne #:#: ____________________________________________

   SSofofttwwarare:e: __________________________________________________________ __

SSofofttwwarare e VVerersisioon:n: ____________________________________________________

   ChecCheck k ReadReaderer MMododeell

________________________________

   RRepeprroogrgramam    NNewew EEquiquipmentpment

IIff PPhonhone e CCode ode NeNeedeeded d fforor DDiiaall OOutut,,

EEntnterer HerHeree:: ____________________

CarCarrriierer:: ____________________________________________________

Additional Terminal #2

Ship Terminal to Agent

Version 121020

Ship Terminal to Merchant In Person Install- MLS

x

PLEASE LIST ALL THIRD PARTY PAYMENT PROCESSORS MERCHANT DOES BUSINESS WITH:

Qty. ___

Qty. ____