merchant processing application

Settlement Network: Agent Name: Agent #: MCC:

Legal Business Name: Business Name (DBA):

Federal Tax ID # (TIN)/Employer Identification # (EIN): Social Security # (Sole Proprietorships only):

Mailing Address: Location Address:

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

Business Phone: Contact Name (First): (Last):

Business Fax: Time in Business: years months

Business Email: Business Website:

General Comments:

Specific Type of Product(s)/Service(s) Sold:

Method of Sales (total must equal 100%) : Swiped: % Keyed: % Internet: % MOTO: %

Merchant Type: Retail Retail w/Tip Mail/Phone Lodging

Convenience Public Sector Internet Petroleum Pay at Pump

Restaurant Fast Food Utility Petroleum Pay Clerk

Cash Advance/Banks Only Business to Business: B2B: % B2C: %

Type of Ownership: Sole Prop Non-Profit LLC Tax Exempt

Corporation Legal/Medical Corp. Partnership Government

Trust Estate Assoc. Other:

Business Location: Store Front Office Home Other:

Method of Marketing: (attach examples) Newspaper Direct Mail Magazine/Catalog

Internet TV/Radio Outbound Telemarketing

Mail, Telephone or Internet Sales Does Merchant use third party to store, process or transmit

Who performs product/service fullfillment? cardholder data? No Yes

Merchant Vendor/Fulfillment House Third Party Name:

Vendor Name: Third Party Address:

Vendor Address: Third Party Phone:

Vendor Phone: Software Used by Third Party:

Customer Return Policy: Refund w/in 30 days Exchange Only None Other:

Does merchant require a deposit? No Yes % Required:

Number of Days Until Product/Service is Delivered:

Mastercard/Visa/American Express/Discover sales transactions are settled: Date of Order Date of Shipment Other:

MERCHANT PROCESSING APPLICATION

First Data-Omaha

GENERAL INFORMATION

Important Notice: Failure to provide accurate Legal Business Name, TIN, EIN and/or SSN may result in a withholding of merchant funding per IRS regulations. See Part V A.4 of the

Merchant Services Program Guide for further information.

BUSINESS INFORMATIONVisa/Mastercard/Discover Annual Volume American Express Annual Volume Average Ticket High Ticket

i3 Verticals, LLC is a registered ISO of Deutsche Bank AG, New York, NYi3VDB2401 of 4 i3VDB2401

Has Applicant ever accepted credit cards before? No Yes If Yes, who was your processor?

Has Applicant ever had a previous credit card processor terminate its merchant account? No Yes If Yes, by whom?

Explanation for prior closure (attach additional pages if necessary):

Former Merchant Number(s):

Bank Name: Contact Name: Bank Phone:

Transit # (ABA Routing): Account # (DDA):

Date: Type of Building: Square Footage (approximate):

Inspector's Comments:

Sales Agent's Signature: Inspector's Signature:

PRINCIPAL (1)

Full Name: Title: Percent Ownership: %

Address: City: State: Zip:

Date of Birth: SSN: Phone: Email:

PRINCIPAL (2)




PRINCIPAL (3)




PRINCIPAL (4)




Visa/Mastercard/Discover Amex Optblue Amex Direct - Existing SE#:

PIN Debit WEX/Voyager EBT - FNS#:

PROCESSING HISTORY

BANKING INFO

MERCHANT SITE SURVEY (to be completed by Agent)

I have verified the identification of the above listed principal(s):

Under the penalty of perjury and accountability, I hereby certify I personally

conducted this premises inspection described above and hereby certify that this

business is legitimate.

***IMPORTANT - COMPLETE THE FOLLOWING SECTION AND INCLUDE A VOIDED BUSINESS CHECK FROM ACCOUNT***

PRINCIPAL/BENEFICIAL OWNER(S)Provide the following information for each individual who owns, directly or indirectly, 25% or more of the equity interest of your business.

See Paragraph 1.9 of the Merchant Services' Program Guide for details regarding limited acceptance.


CARD ACCEPTANCE (check all that apply)

% %

%

% %

% %

% %

%

%

%

$ $ Pass Dues & Assessments $

$ $ $ $

$ $ %

$ $

$ $

Billing Method: Monthly Daily $

$ $ $ eIDS Access Fee $

$ $ $

$ $

$ $ Regulatory Product Bundle $

% % $

$

% %

$ $ $ x $ x

$ $ x $ x

$


Statement Fee

Monthly Minimum Discount

PCI Compliance Monthly Fee

PIN Debit Trans Fee

Qty

Setup Fee

Monthly Fee

Auth Fee

Qty

Monthly Fee

PIN DEBIT/EBT PRICING(plus applicable network fees from the Debit Networks)

PIN Debit Discount EBT Discount

Monthly Debit Access EBT Trans Fee

Other Volume % Rate

Other Item Fee

Interchange Clearing

MONTHLY FEESMISCELLANEOUS FEES

Application Fee

Invalid TIN Fee

ACH Reject Fee

PCI Non-Compliance

Chargeback Fee

Retrieval Fee

Annual Fee

PCI Annual Fee

MC License Fee

Visa Access Fee

MC Access Fee

AVS Fees

Return Trans Fee

WEX Trans Fee

Voyager Trans Fee

TransArmor Fee

eIDS/Dispute Manager

Regulatory Product Fee

Data Breach Protection

Inactivity Fee

Setup Fee

WIRELESS FEES(per Wireless Setup)

GATEWAY FEES(per Gateway Setup)

V/MC/DV (Credit) American Express

V/MC/DV (Debit)

SCHEDULE OF FEESPASS THROUGH PRICING

(plus applicable interchange rates and program fees from V/MC/DV/AX)

DISCOUNT RATE DISCOUNT RATE

TIERED PRICING

DISCOUNT RATE DISCOUNT RATE

V/MC/DV Qual (Credit) American Express Qual

V/MC/DV Qual (Offline-Debit)

V/MC/DV Mid-Qual (Offline-Debit)

V/MC/DV Non-Qual (Offline-Debit)

V/MC/DV Mid-Qual (Credit) American Express Mid-Qual

V/MC/DV Non-Qual (Credit) American Express Non-Qual

AUTHORIZATION/TRANSACTION FEES REGULATORY & ASSOCIATION FEES

V/MC/DV Auth Fee

Amex Auth Fee MC Per Location Fee

Sales Trans Fee

Batch Fee

Voice Auth

Commercial Card Interchange Service Yes No With the Commercial Card Interchange Service, when transactions do not include any tax information we will compute the sales tax

based on the applicable rate at your location to allow you to obtain the best interchange. When we compute the sales tax on your behalf, we will retain 75% of the interchange savings. If a transaction is fully or partially

exempt, you should enter the tax amount (even if that amount is $0.00) as CCIS applies your local tax rate to the full amount of transactions when the prompt is bypassed.

The following fees will be passed through to merchant if applicable: Visa Assessment CR/DB, Int'l Service, Int'l Service Enhanced, Acquirer Fee High Risk, Auth Processing CR/DB, Int'l Auth Processing CR/DB, Account

Verification CR/DB, Int'l Account Verification, Misuse of Auth, Zero Floor Limit, Trans Integrity CR/DB, Partial Auth Non-Participant, File Transmission, Acq Credit Voucher Data Processing Return CR/DB, Int'l Acq Credit

Voucher Data Processing Return CR/DB, FANF, Staged Digital Wallet, and Dispute Image; Mastercard Dues and Assessments, Dues and Assessments Large Ticket, Cross Border, NABU, Account Status Inquiry Service-Intra-

regional, Kilobyte, Acquirer Per Item Support, ICA AVS CP/CNP, CVC2, Digital Enablement, Global Wholesale Travel B2B, SecureCode Trans, Processing Integrity Pre Auth, Processing Integrity Undefined Auth, Processing

Integrity Final Auth, Processing Integrity Final Auth Min, Processing Integrity Invalid Acquirer ICA, Processing Integrity Message Format, Processing Integrity Image, Freight Program, Excessive Auth, Nominal Amount Auth,

Interchange Compliance Downgrade, Processing Integrity Reversal, ICA AVS, Dispute Case, and Dispute Image; Discover Assessments, Data Usage, Int'l Service, Int'l Processing, Network Auth, and Card Account

Verification; American Express Network Auth Fee; PIN Debit Network Annual Fees.

If applicable, we may also charge fees to Merchant for the specific circumstances as described in Section 25 of the Program Guide. See Section 25 of the Program Guide for other charges that may apply.

Optblue Program Fee %

Client’s Business Principal/Officer:

Signature X Date Print Name Title



Personal Guarantee Signature X Date Print Name

Personal Guarantee Signature X Date Print Name

Accepted by i3 Verticals, LLC Deutsche Bank AG, 60 Wall St., New York, NY 10005

Signature X Signature X

Date Title Date Title

i3VDB2401 of 4 i3VDB2401

I understand that upon AXP’s approval of the Application, as applicable, the entity will be provided with the Agreement and materials welcoming it to AXP’s Card acceptance program.

Client authorizes i3 Verticals, LLC and Bank and their affiliates to debit Client’s designated bank account via Automated Clearing House (ACH) for costs associated with equipment hardware, 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 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 the Office of Foreign Assets

Control (OFAC).

Client certifies, under penalties of perjury, that the federal taxpayer identification number and corresponding filing name, and all beneficial ownership information provided herein are complete and 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 i3 Verticals, LLC and Bank.

Personal Guarantee: In exchange for i3 Verticals, LLC and Deutsche Bank AG (the Guaranteed Parties) acceptance of the Agreement, the undersigned unconditionally and irrevocably guarantees the full payment and

performance 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 agreements and 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 any and 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 the Guaranteed Parties are relying upon this Personal Guaranty in

entering into the foregoing agreements, as applicable.

i3 Verticals, LLC is a registered ISO of Deutsche Bank AG, New York, NY

Early Termination Fee $__________. The initial term of this Agreement is three years from the date of your

approval by our Credit Department (the Initial Term). If you terminate this Agreement before the end of the then

current term or otherwise stop processing your transactions with us, you will be charged this Early Termination

Fee. After the Initial Term, subject to Part IV, Section A.3, this Agreement shall automatically extend for an

additional period of one year each (each an Extended Term).

SIGNATURES

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 Guide [Version i3VDB2401] and Confirmation Page,

which is part of this Merchant Processing Application (consisting of Sections 1-9), and by this reference incorporated herein. Client acknowledges and agrees that we, our Affiliates and our third party subcontractors and/or

agents may use automatic telephone dialing systems to contact Client at the telephone number(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 if the 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 solicitation purposes. Client

hereby consents to receiving commercial electronic mail messages from us, our Affiliates and our third-party subcontractors and/or agents from time to time. 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 approved based upon contrary information stated in Section 5, Transaction Information section above, you are authorized to

accept transactions in accordance with the percentages indicated in that section.

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 from any 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 any purpose 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 reports and 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 law and 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 and business 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/or agents 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 banks and 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/or automated

electronic computer security screening, by us or our third-party vendors.

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 i3 Verticals, LLC 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 information about me personally, including by requesting reports from consumer reporting agencies from time to time, and disclose such information to their agent,

subcontractors, Affiliates and other parties for any purpose permitted by law. I authorize and direct i3 Verticals, LLC and AXP and AXP agents and Affiliates to inform me directly, or inform the entity above, about the

contents of reports about me that they have requested from consumer reporting agencies. Such information will include the 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 understand the English language. Please read the American Express Privacy Statement at

http://www.americanexpress.com/privacy to learn more about how AXPs protects your privacy and how AXP uses your information. I understand that I may opt out of marketing communications by visiting this website or

contacting American Express at 1-(800)-528-5200.

Title Date

______________________________________________________________________________ Please Print Name of Signer

i3 Verticals

merchant processing application

Documents