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CAG-11-094, Adden #1-13
Amendment
To
Master Customer Agreement eCG011011-REN
Between EnerGov Solutions and City of Renton,Washington
This document amends the Master Customer Agreement("Master Agreement"),(included by reference)between
EnerGov Solutions,LLC(EnerGov'),a Georgia limited liability company located at 2160 Satellite Blvd,Suite 300,
Duluth,Georgia 30097,and the City of Renton,Washington,("Customer")located at 1055 S.Grady Way,Renton,
WA 98057
The Effective Date of this Amendment is O Rhef 2012.
EnerGov and Customer desire to modify the Master Agreement to allow Customer the use of EncrGov's MyGovPay
and/or VirtualPay to accept credit cards tluough the EnerGov Citizen Assess Portal or.duectly into the EnerGov
Software used internally by the Customer.
Therefore,in consideration of the mutual promises and responsibilities described below,the parties agree as follows:
1. Existing Contract and Amendments. All terms and conditions and previous amendments of the Master Customer
Agreement not herein amended shall remain in.full force and effect. .
2. Definitions. The following definitions shall apply to this document.
"BCSW"means BankCard Services Worldwide,a Payment Card Industry(PCI)compliant processing agent
through which EnerGov passes credit card transactions. -
"Merchant Agreement"means agreements between Customer and BCSW which provides for the Merchant Fees.
"Merchant Fees"means direct costs levied by Visa/Mastercard/Discover or other payment card companies for
Interchange Fees,Dues,Assessments and Occurrence Fees,over which EnerGov has no authority and which
are defined in the Merchant Agreement.
"Use Fees"means the Technology Fees,Authorization Fees and Program/Convenience Fees as listed in Table 1.
3.MyGovPay/VirtualPay.
3.1 If Customer elects to utilize MyGovPay and/or VirtualPay, products of EnerGov (Powered by BankCard
Services Worldwide), designed for citizen users for processing online payments, then the Use Fees listed in
Section 3.3 below will apply, and
i) Customer agrees that Merchant Fees are direct fees levied by Visa,MasterCard,Discover,or other payment
card companies and are not subject to this Amendment,and
i) Customer agrees that Use Fees are separate from any Merchant Fees,and.
ii) Customer agrees that this document in no way represents any modifications to Customer's Merchant
Processing Agreement(provided separately)between Customer and BCSW,and
iii) Customer agrees the.Use Fees listed in Section 3.3 for use on the MyGovPay online system and/or the
VirtualPay back-office system will not be deposited or owed to Customer in any way.
3.2 Customer acknowledges that the ability to assess these fees., including Use Fees, is dictated by the Card
Associations, whose rules may change at any time and for any reason. If MyGovPay is unable to process
payments using any of these Use Fees, Customer agrees that EnerGov may negotiate a new pricing model with
Customer for the use of MyGovPay and/or VirtualPay.
3.3 Customer and EnerGov agree that the following Use Fees are current as of the Effective Date of this
Amendment.
Customer Initials:
FaterGov Contract Amendment—Renton,WA
EnerGov Initials:
Page 1 of 2
3.4 EnerGtav will.provide Customer 60�days written notice in advance of the end of any initial or subsequent term
of this Amendment of any proposed increase in Use Fees;
4. Term. The term of this Amendment shall be for three(3)years ("Initial Term") commencing on the Effective
Date and will automatically renew annually unless 30-days written notice is provided by either party to the
other prior to the end of the Initial Term or any subsequent term.
Table 1—Use Fees
VirtualGov Payment Processing Fees
Online Payments(MyGovPay)—Without Convenience Fee
Technology Fee 30%per Transaction(1)
Authorization Fee $0.30 per Transaction(1)
(1)Technology Fee and Authorization Fee reduce total amount received by Customer.
BackOffice Credit Card Processing Only(VlrtaalPay)
Technology Fee .30%per Transaction(1)
Authorization Fee $0.30 per Transaction(1)
(I)Technology Feer and Authorization Fee reduce total amount received by Customer.
IN WITNESS WIEREOF,the parties have executed this Amendment under seal as of the Effective Date.
f
CITY OF RENTON WASMINGTON ENERGOV S,LLC
By:
Printed Name: Iwen Wang Printed Name: y�` '
Title: Adminstrative Services Administrator Title: Executive Vice President
EnerGov Contract Amendment—City of Renton,WA i
Page 2 of 2
0 •
llcrchants Business dame Q_egal}: City of Renton,WA MERCHANT APPLICATION
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BankCard Services
WORLDWIDE
Please carefully complete the enclosed Application and read the attached Terms and Conditions and other additional
forms, as applicable to you, which together make up the Merchant Processing Agreement. Keep a Copy of the entire
Application and the Terms and Conditions for your records. Your Application is subject to National Processing
Company ("NPC")/Member Bank's underwriting review process. NPC/Member Bank's acceptance of this Application
will be made in a manner authorized in the attached Agreements.
Office Address:
940 Hastings Ave
Saint Paul MN 55071
Phone:800-838-%99
Fax:866-578-5353
Section 1
IMPORTANT DISCLOSURES Merchant further acknowledges receipt of NPC Documentation,which includes Merchant Processing Agreement VER.GEN.2-12
MEMBER BANK IMPORTANT MEMBER BANK RESPONSIBILITIES:
First National Bank of Omaha 1.A Visa Member is the only entity approved to extend acceptance of Visa products directly to a Merchant.
One First National Center 2.A Visa Member must be a principal(signer)to the Merchant Agreement.
16th and Dodge Street 3.The Visa Member is responsible for educating Merchants on pertinent Visa Operating Regulations with which Merchants must comply.
Omaha,NE 68197 4.The Visa Member is responsible for and must provide settlement funds to the Merchant.
ph:402-341-0500 5.The Visa Member is responsible for all funds held in reserve that are derived from settlement.
IMPORTANT MERCHANT RESPONSIBILITIES:
(1)Ensure compliance with cardholder data security and storage requirements. The responsibilities listed above a imp not supersede the terms r the Merchant Agreement and
(2)Maintain fraud and chargeback below thresholds. are provided to ensure the Merchant understands some important obligations of each part}'
(3)Review and understand the terms of the Merchant Agreement. and that the Visa Member(Acquirer)is the ultimate authority should the Merchant have any
(4)Comply with Visa Operating Regulations.
problems.
Section 2
PATRIOT ACT AND BACKGROUND AUTHORIZATION
To help the government fight the funding of terrorism and money laundering activities,the USA Patriot Act requires all financial institutions to obtain,verify and
record information that identifies each person(including business entities)who opens an account.What this means for you:When you open an account,we will ask
for your name,physical address,date of birth,taxpayer identification number and other information that will allow us to identify you.We may also ask to see your
driver's license or other identifying documents.The undersigned entity(ies)and individuals hereby unconditionally authorize NPC and Member Bank or its agents to
(i)investigate the information and references contained herein,and to obtain additional information about the Merchant and such individual(s) by pulling credit
bureau and criminal background checks on the Merchant and its principals,including obtaining reports from consumer reporting agencies on individuals signing
below as an owner or general partner of Merchant,or providing their Social Security Number on the Application (if such individual asks NPC or Member Bank
whether or not a consumer report was requested,NPC and/or Member Bank will tell such individual and,if NPC and/or Member Bank received a report,NPC
and/or Member Bank will give the individual the name and address of the agency that fumished it)and(ii) update such information periodically throughout the
terms of service of the Merchant Agreement By providing your 55N and signing this Application,you,in your individual capacity,unconditionally authorize NPC
and Member Bank to obtain your consumer credit report.
NPC GOVT.2-12.IMA National Processing Comppany NPC')is a registered ISO/MSP of First National Bank of Omaha,Omaha,NE Pare 1 of 4
BankCard Sen�ices Y'orldwde("BCS�"')is a registered ISO/MSP of First National Bank of Omaha,Omaha NE b
r
Sales Representative ID Number(9 digit code)or Sales Code(16 digits) Merchant's Business dame(lxgai): City of Renton,WA
LLJBank#or,Nferchant Association#:
Section 3 BUSINESS INFORMATION ❑ Corporate lieadquarters
Business Legal Name:(Must Match Business Tax Return Name) Contact Name:
City of Renton,WA Kristi Rowland
Business Name(DBA): Email address: \Vebsite:
City of Renton,WA KRowland @Rentonwa.gov www.rentonwa.gov
Business Location Address: Business Billing Address:(if different from location address).
1055 S Grady Way 1055 S Grady Way (Attention Kristi Rowland,Finance 5th floor)
City,Scare,Zip: City,State,Zip:
Renton,WA 98057 Renton,WA 98057
Phone#: Fa_e M Phone#: Fax#:
425.430.6400 425.430.6947 425.430.6957
Section 4 OWNERSHIP INFORMATION
Ownership: ❑ Sole Prop. ❑ Corporation ❑ Tax-Exempt Organization(501C) Tide: Federal Tax ID#: D&B#:
❑x Government(Federal/State/Local) ❑ LL.0 ❑ Partnership Admin.Srves.Administrator 91-6001271
Owner/Officer/Principal Name•. DOB: SSN#:
lwen Wang
Home Address: City,State,Zip: - Phone M
1055 S Grady Way Renton,WA 98057 425.430.6400
Section 5 BUSINESS PROFILE AND ASSUMPTIONS
#of Locations: ❑ Add'1.Location 1st Location MID: 0 % =Card Present 100 ,o =Card Not Present Percent of Sales
Ownership or Legal Close NPC Existing MID#: Close Date Existing MID:
Entity Change 0 %Card Swipe 0 % MOTO 50 %To Consumer
Open Date: Date of Current Ownership: 0 % Imprint 100 %Internet 50 °/To Business
01/01/1900 1 (Manually Keyed)
Annual Volume(Visa/MC/DS): Average Ticket(Visa/MC/DS): Highest Ticket(Visa/MC/DS):
$1.5 million $25Q $1 Q 000 Type of Goods/Service Sold Permits,inspections,and other services
❑X Never Accepted Cards ❑ Processor Change- How many processing statements are you including? %of International Cards %
REFUND POLICY(Check One): ❑No Refund ❑ Refund in 30 days or less ❑ Merchandise exchange only ❑X Other
SeasonaiSales: ❑ Yes Q No Active Months:[]JAM ❑ FEB ❑ MAR ❑ APR ❑ MAY ❑JUN ❑JUL. ❑ AUG ❑ SEP ❑ OCT ❑ NOV❑ DEC
Section 6 COMPLIANCE INFORMATION
Do you(MERCHANT)have a Q 3rd party software application/gateway or ❑ POS Terminal Have you been notified by Visa,MasterCard or Discover that you have been the the victim of a
compromise of cardholder data? ❑ YES ❑X NO
Are you compliant with the Payment Card Industry Data Security Standards? 0 YES ❑ NO
If yes,have you completed remediation? []YES NO
If yes,identify Security Assessor and certificate number. enerGov Do you store cardholdet data? Paper- ❑YES o NO Electronic- ❑YES (E NO
Last Certification Date: on all third parties that have access to cardholder data
on your behalf(f so,Section 12 must be completed):
All merchants must comply with the Payment Card Industry Data Security Standard(°PCI DST). Merchant is required to maintain the security of card data and to comply with the requirements of the
PCI DSS.Merchant must validate its compliance with the PCI DSS and provide NPC with evidence that Merchant(a)has successfully completed a Setf Assessment Questionnaire and scan(s),if
applicable,and(b)is compliant with the PCI DSS. NPC has created the PCI Program(tire"PCI ram")to assist merchants in securing card data and complying with PCI DSS.You are enrolled in
the PCI and the applicable fees wig be assessed in accordance with the terns of the PCI m. Information on the PCI Program is set forth in Section 14.0 of the Terms and Conditions
and the a�ppamWe fees are set forth in Section 10.
Section 7 MERCHANT BANS ACCOUNT INFORMATION Please supply voided check or preprinted bank letter for each account requested.
Deposit Time Frame Q Premium ACH ❑ Alternate Funding" In accordance with the terms set out in the Merchant Processing Agreement,funds will be transferred ro/from the account as
Deposit Type. x Combined ❑ By Batch delineated. If nothing is checked,MERCHANT will receive Premium ACH. *Subject to special approval.
DDA Aaounr Ty ACH can be performed by the following entities: Member Bank,NPC or any authorized
Routing#1 1 2 5 0 0 0 1 0 5 ❑x Checking f5 Savings agent of NPC or any Third Party Service Provider with whom you have contracted.
Account#IFT—F-571M 5 0 0 6 9 8 3 1 2 1 6 1 1 1 J I I If more than one account is indicated this account will be used for Sales.
DDA Account T}
Routing#2 ❑ Checking Savings
Account#2 If a second accovn this account i used for.
Discount Fees Credits Char backs
Any ACCOUNT NUMBER indicated must be a valid account number for handling ACH deposits and withdrawals.
if Check Services are selected and by signing Merchant Processot 1 Agreement,Merchant agrees to accept Check Services pursuant to,and to be bound by,the terms and conditions for
Section 8 CHECK/ Check products acceptance as stated in the Merchant Processing Apreaman�or as provided by Check services provider.GETI w other service provider. Member Bank is not providing
the Check/ACH Services.Merchant must be approved by NPC and ifs service provider.GETi,or other service provider. ++Gdheck Recovery An inactivity Fee•of$5.00 per month may
CH SERVICES be charged attar S months of inactivity.+++For Non-Guarantee checks 510,000 and greater.A premium of.10%(ten basis points)w A be charged in addition to the discount rate.
These fees a oWv gier account.
Discount Trensanion Discount Transaction Other
Check Service Rate Fee Check Service Discount Fee Check2l Fees
Check Conversion w/ ® Check2l POS-Guarantee Check2l Return Fee"' $5.00
Guarantee Check2l POS-Non-Guaramcc+++ *:
oCheck Conversion Check2l Remote-Guarantee
w/o Guarantee Check21 Remote-Non-Guarantee+++ Monthly Check2l Access Fee^'*: $5.U0
Paper Check w/ 8 Check2l POS Payroll option-Gsarmtrec Discount Ram+3%premium
Guarantee Check2l POS Payroll option-Nod-Gwruster.. Discount Rate+1%premium
#of Checks Monthly-. Average Amount: largest Check Amounr. Monthly Service Fee"•': Batch Fee: Monthly Aiinimurri': Annual Fee"-: Termination Fee"*':
$25.00 $59.95 $125.00
❑ Monthly Billing ❑ Check Recovery Service++
NPC(rOVT.2-12TNlA National Processin Com�pPany 'NPC' is a registered ISO MSP of First National Bank of Omaha,Omaha,NE Page 2 of 4
BankCard Services 'orldwic! BC S� 7 is a registered IS./MSP of 1 first National Bank of Omaha Omaha NE
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Merchant's Business dame(Lego: City of Renton,WA
Section 9 SCHEDULE OF FEES DISCOUNT: ❑ Daily x❑ Monthly Card Acceptance Options: ❑ Dcbit Card Only ❑ Other Cards ❑x All Cards
BUSINESS TYPE ❑ Retail ❑ Restaurant❑ Mail/Telephone Order Q Internet.Only ❑ Lodging ❑ Fuel ❑ Supermarket ❑ Cash Advance
SUB BUSINESS TYPE ❑ Retail/Key Entered ❑ MOTO/Card Swipe ❑ Dial Pay Caprurc ❑ Health Care
SPECIAL PROCESSING ❑ FPS ❑ Large Ticket ❑ Level III Data ❑ Utility
VISA/MASTERCARD/DISCOVER Rate Category Discount Rate Transaction Fee ❑ Debit PIN-Based Monthly Fee Discount Rare Transaction Fee
Debit Non PIN-Based Processing F"93 0.30 0 (Debit Network Interchange and other fees
Visa,MasterCard and Discover Interehutge fees,assessments /o +$ 0.00 and sponsorship,switch and gateway fees will $ % $
and other fees will also be passed through to Merchant) also be paused through to Merchant
Credit Processing Fees
(Visa,MasterCard and Discover Interchange fees,assessments 0.30 % $ 0.30
and other fees will also be passed through to Merchant
❑Flat Rare Discount Rare
PnKessor ❑ Secure3 Quantity Scrup Fee Monthly Hosting Fee Transaction Fee
American Transaction Feett Or other Internet I I I I+$
Express Franchise CAP 0i ° E] Food Stamps Monthly Fee Transaction Fee
/o $ 0.30 ❑ EBTr3 E] Cash Benefits +
❑New ❑Existing Both $
Existing Account#: FCS Account#:
Quantity Setup Fee Monthly Hosting Fee Transaction Fee El voyagert*
❑ Wireless Check box for service. Additional paperwork required.
Service3 $ $ +$ ❑ Wright Expresst'
VISA/MASTERCARD/DISCOVER Tier Rate Category Discount Rare Transaction Fee VISA/MASTERCARD/DISCOVER Tier Rate Category Discount Rate Transaction Fee
Mid Qualified Exceptionl + °
(Appbes to Retail:Merchants Only) �O +$ Non Qualified Exception2 + % +$
Transaction fees are charged for all transactions including without limitation,any interaction between Merchant and a customer,any authorization attempt,credit,closing and capturing daily sales
batches and any other transactions which makes use of any NPC service.1This is added to the Credit Processing Fee discount rate and transaction fee.2This Is added to the mid-qualified discount
rate and transaction fee for retail,which is the Credit Processing Fee rate plus the Mid-Qualified Exception,or the Credit Processing Fee discount rate and transaction fee for MOTO.3TNs transaction
fee will be in addition to the applicable qualified,mid-qualified or non-qualified transaction fee for the transaction,regartless of how the transaction qualifies, t'These services will be provided to you
and funded by independent third party service providers,not by NPC or Member Bank. Neither NPC nor Member Bank makes any warranty with respect to these services.American Express may
assess in addition to above,a transaction fee of$.10 or$.15,a statement fee and downgrade surcharges. See Page 4 for additional information regarding American Express.Voyager and Wright
Express may assess other rates and fees.ttSame as qualified transaction fee if left blank;.it qualified transaction fee is left blank the fee will be$.30.
Section 10 OCCURRENCE FEES Paper Statement ❑ YFS /month [j]x NO
/year or
On File Fee $15.00 PC1 Program Feet SAQ
/month Retrieval/Chargeback /each /year C-D
Batch Feett /each ❑Gold Service Package /month Annual Fee: Charged in Month of
Voice Authorization $0.95 /each ❑Service Package /month 1099-K Reporting Is provided at No Charge
ACH/DBA Change Fee $25.00 /each Early Termination Feel /each charged Annually in
Regulatory Accounting atr>„d,nF
Nfinimum Bill /each Assistance Program Fed March
Return ACH(s)are subject to a$25.00 fee for each occurrence. lThe initial term of the Merchant/^^^—^^"-' ^-;and automatically renews for additional 2-year periods. If this Agreement Is
terminated prior to the expiration of the initial term or any renewal tern,you will be subject to an,$1.5 million "("ETF")in accordance with the terms of Section 10.D.ty of the Terms and
Conditions. If limited by state law,your ETF may be modified in accordance with Section 10.0.iv of the Terms and Conditions. 2The higher rate will apply if you use software In your processing
environment or you otherwise qualify as a SAO C or SAO 0 merchant. 3See Section 14.R of the Terms and Conditions for additional information. ttBatch fee Is the same as the transaction fee for
Visa/MC/Dlscover or 300 If the Visa/MC/Discover transaction fee is left blank.Refer to the Merchant Processing Agreement for more information.
Merchant agrees to and accepts the terms and conditions set forth in this Application and the Terms and Conditions which are Incorporated herein by reference as tf fuly set forth herein(collectively,
the"Merchant Agreement")and acknowledges receipt of all parts of the Merchant Agreement. Merchant acknowledges that no handwritten changes have been made to the printed text of the
Merchant Agreement and that the parties may produce and rely on a copy or electronically stored image of the Merchant Agreement for all legal purposes. Merchant represents,warrants and certifies
to NPC and Member Bank that it has reviewed all 4 pages of this Application,that all information provided herein is true,correct and complete and that NPC and Member Bank may rely on the
information contained in this Application,without further Investigation,for all purposes. Merchant acknowledges and agrees that NPC and Member Bank are in no way responsible or liable for the
actions,inactions,performance or lack of performance of any third party provider or independent sales representative. Merchant represents that it has chosen for itself any services,equipment or
third party selected in connection with the Merchant Agreement,and It has not relied on any promises,representations,warranties,or covenants of the independent sales representative,NPC or
others. Merchant acknowledges and agrees that the Merchant Agreement shall not be altered by any prior,contemporaneous or subsequent oral representations made by any party. Merchant further
authorizes release of Merchant information In accordance of the provisions of Section 12E.of the Terms and Conditions.
X JA4,L By initialing here,I ag..the I have read and understand Section 1,Important Disclosures and Section 2,Patriot Act and Background Authorization.
IN WITNESS WHEREOF the parties have caused this Agreement to be executed by their duty authorized representatives effective on the date signed or approved by NPC. The Agreement shall be
birtdmgg upon Merchant upon the earlier of Merchant's execution below or Merchant s first processed electronic transaction.
MERCHANT NATIONAL PROCESSING COMPANY( NPC") MEMBER BANK
Signature(Signature may be evidenced by fact' ature(Sign to may be evidenced by facsimile) Signature (Signature may be evidenced by facsimile)
X X
Name(pkasc prior) ate N me(please prior) �e�_ Date Na (please print) Date
[wen Wang 2A—e-ks, ?,�f c-� cros a14, �on-pAf-K- 11/j/17,
PERSONAL GUARANTEE: In considerafion of the underta kings of NPC contained in the Merchant Agreement,the undersigned("Guarantor"),being interested in the business and success of
Merchant and to induce NPC to enter into the Merchant Agreement,does hereby absolutely and unconditionally guarantee the performance and payment by Merchant of all Merchanrs obligations to
NPC,together with all costs,expenses and attorney's fees Incurred by NPC in connection with any actions,inactions,or defaults of Merchant. The liability of Guarantor shall not be affected by any
settlement,modification,release,waiver,discharge or variation of terms of any obligation of Guarantor,of Merchant,or any other person or by any failure of NPC to exercise or enforce any of its rights
against Merchant. Each Guarantor hereby waives every kind of notice to which the Guarantor might be entitled and agrees that the Guarantees liability shall not be affected by any act or omission of
NPCIMember Bank,or indulgence granted by NPC/Member Bank,respecting Merchant;In addition,Guarantor specifically waives notice of acceptance of guarantee,notice of demand,prosecution of
collection,all exemption and homestead laws and all setoffs and counterclaims. This guarantee shall be governed by and construed in accordance with the laws of the Commonwealth of Kentucky.
Guarantor agrees,in the event of arty dispute regarding this guarantee,the courts of the Commonwealth of Kentucky shall have and be vested with personal jurisdiction over Guarantor. Any lawsuit
or other action arising directly or indirectly out of this guarantee shall be litigated exclusively In a Stale or Federal court located in Jefferson County,Kentucky. The Guarantor waives any right to
require NPC to proceed against other persons or Merchant or to require Merchant to comply with the Merchant Agreement. This is a guarantee of payment and not of collection. This is a continuing
guarantee and shat remain In effect until 180 days after receipt by NPC of written notice by Guarantor terminating or modifying the same. The termination of the Merchant Agreement or this
guarantee shall not release,Guarantor from liability with respect to any obligation incurred prior to the effective date of termination. This guarantee shall not be affected by the dissolution of Merchant,
by any change in legal status of Merchant or any change in the relationship between Merchant and Guarantor. This guarantee binds and inures to the benefit of the personal representatives,heirs,
administrators,successors and assigns of Guarantor and NPC. By signing this guarantee,the Guarantor authorizes NPC to obtain Guarantees consumer credit report and/or a criminal background
check.
.Aurhorized SiEmarvre of Guuanrnr:(Do Not Includc'ridc) Sxial Sscu 4#: _ Date of signarurc:
X
Nun<of Guaranmr.(M,Not ladude'tirk) Merchant 1c0 Name:
NPC GOVT.2-I2,11MA National Processing Con an NPC''is a registered ISOAISP of First National Bank of Omaha,Omaha,NE Page 3 of 4
BankCard Sete" 1k`orkfuide RCSW is a registered ISO/XfSP of First National Bank of Omaha,Omaha NE
Merchant's Business Name(Legal): City of Renton,WA
Section 11 PROVIDER CODE: NPC=NPC to ship equipment SOF=Sales office to ship equipment MER a Merchant Owned
EQUIPMENT SETUP
TERMINAL QTY MEM.SIZE PROVIDER PROVIDER
PRINTER PIN p� PROVIDER
CODE CODE CODE
❑NEW ❑EXCHANGE
❑NEW❑EXCHANGE
❑VFW ❑EXCHANGE
Other. _ Provider Code: Tther. Provider Code: Other. Provider Code:
EQUIPMENT SOFTWARE INFORMATION
SOFTYY'ARE NAME PUBLISHER
VERSION
EQUIPMENT OPTIONS THE DEFAULT SELECTION WILL BE APPLIED FOR ANY OPTION NOT SELECTED BELOW
❑ RETAIL/MOTO ❑ RESTAURANT ❑ CASH ADVANCE
AVS Both ❑ YES ❑ NO Auto-Close++ ❑ ITS ❑ NO Tips ❑ YES ❑NO ❑ LODGING
AVS ZIP Only ❑ YES ❑ NO TIME Severs ❑ YES ❑ NO
Last 4-Digits ❑ YES ❑ NO Store N Forward PASSWORD
❑ YES ❑ NO Tables E] YES E] NO
CVV 2 ❑ YES ❑ NO Pre-Dial ❑ YFS ❑ NO Bar Tab ❑ YES ❑ NO All ❑ YES ❑NO
Purchase Card/Level 2 ❑ YES ❑ NO Cash Back ❑ YES ❑ NO Suggested Tip ❑ YES ❑ NO Void ❑. YES ❑ NO
Invoice#Prompt ❑ 1'ES ❑ NO Debit Cash Bank
PBX CAde ❑ g ❑ 9 Max Amount, ❑ FAST PAY(FPS) Return ❑ YES ❑ NO
Multi-Merchant ❑ YES ❑ NO ++Auto-Close Time for Alternate Funding ❑ Both receipts signature line Settlement ❑ YES ❑ NO
First Merchant MID needs to be no later than 7:30 p.m.CST ❑ Both receipts NO signature line
❑ NO receipts under$25.00 Other
Custom Header/Footer. Wireless ID:
Comments:
EQUIPMENT SHIPPING INSTRUCTIONS Required ONLY if ordered through NPC-Default shipping options(indicated by+)will be applied for any option not selected below
Ship To: ❑ Merchant Location* ❑ ISO Location ❑ Other ❑ 1-3 Day ❑ Over Night Priority" ❑ Ground ❑ Saturday
Ate; Payment For Equipment Will Be:
❑ Lease ❑ Check ❑ Cash ❑ 30 Day(Bill Group)
Address: ❑ Visa ❑ MC ❑ Disc ❑ Amex
City. State: Zip: Phone#:
❑ Special Instructions:
NPC TO REPROGRAM/TRAIN MERCHANT? ❑ Yes ❑ No NPC TO SHIP WELCOME KIT? ❑ Yes ❑ No
WELCOME KIT SHIPPING INSTRUCTIONS Required if welcome kit is shipping to separate address from above
Ship To: ❑ Merchant Location` ❑ ISO Location ❑ Other Attn:
Address:
City. State: Zip: Phone#:
Section 12 THIRD PARTY VENDOR DATA 'Phis section is for reporting third- arty vendors that have access to merchants data.
Software Vendor. Version# Merchant data to which this vendor has access:
USAePay
Does suftware store cardholder information? ❑x Yes ❑ No Is vendor software PCI compliant? ❑x Yes ❑ No
Section 13 SITE INSPECTION INFORMATION
I represent and warrant that the information wet forth in the application is true and accurate to the best of my knowledge. In addition,I hereby certify,that(check which applies):
I have physically inspected the business premises of the merchant at this address,perasmaily Business/Inventory/Shipments:
❑ confirmed the identity of the person fisted in the Owner/Officer Information Section,and Does business appear as represented? ❑ Yes ❑ No
witnessed their signing of the Agreement Is business open and operating? ❑ Yes ❑ No
Is inventory sufficient for business rape? ❑ Yes ❑ No
❑ An NPC approved third parry site inspection vendor will supply inspection within IS days Are goods and services delivered at the time of sale? ❑ Yes ❑ No
of my signature below or f have informed NPC that a site inspection is needed. Goods and services charged o credit card on
B� ❑ Order ❑ Shipment
I have not physically inspected the business premises of the Merchant but have verified the 1 f gourds are shipped,is a Fulfillment House used? ❑ Yes ❑ No
avalidity of the business using outside sources and confirmed the identity of the person listed
under the Owner/Offices Information Section. Fulfillment House: °o of shipments by this vendor
Location Type: ❑ Retail Store Front ❑x Office Building ❑ Industrial Building ❑ Residence ❑ Trade Show
Sales Organization: Sales Rep Signature: Application Date:
APPLICABLE ONLY IF MERCHANT ACCEPTS AMERICAN EXPRESS:By signing this Application.I represent that I have read and am authorized to sign and submit this application on behalf of the entity above and all
information I have provided herein is true,complete,and accurate. 1 authorize American Express Travel Related Services Company,Inc.("American Express')to verify the information on this Application and to receive and
exchange information about me personalty,including by requesting reports from consumer reporting agencies. I authorize and direct American Express to inform me directly,or through the entity above,of reports about me
that American Express has requested from consumer reporting agencies. Such Information will Include the name and address of the agency fumishing the report.1 also authorize American Express to use the reports from
consumer reporting agencies for marketing and administrative purposes. 1 understand that upon American Express'approval of the entity indicated above to accept the American Express card,the terms and conditions for
American Express®Card Acceptance(Terms 6 Conditions)win be sent to such entity along with a Welcome Letter. By accepting the American Express card for the purchase of goods andlor services,or otherwise indicating
its Intention to be bound,the entity agrees to be bound by the Terms and Conditions. A$7.95 monthly flat fee is mandatory for MOTOAntemetlHome based businesses. American Express services will be provided to
Merchant and funded by independent third party service providers not by NPC or Member Bank. Neither NPC nor Member Bank makes any warranty with respect to these services, The Processor Transaction Fee stated in
Section 9 is in addition M any tees assessed by American Express.
NPC GON'T.2-12.IN1A National Processin Com�ppany NPC')is a registered ISO/A1SP of First National Bank of Omaha Omaha tiff
BankCard Services G'oridv BCSW'l)is a registered ISO/MSP of First National Bank of Omaha,Omaha NE Page 4 of 4