1 Blackstone1605 MERCHANT PROCESSING APPLICATION AND AGREEMENT Blackstone1605(ia) Sales Office Print Sales Rep Name Sales ID# Merchant Number Sales Rep Signature Phone# Client s Business Name (Doing Business As): 1. BUSINESS INFORMATION Client s Corporate/Legal Name (Use Also For Headquarter s Information): Page 1 of 4 Business Address: Billing Address (If Different Than Location Address): City: State: Zip: City: State: Zip: Location Phone #: Location Fax: Contact Name: Business Address: Contact Fax # / Address: Business Website Address: Contact Phone #: Customer Service Ph # Customer Service Address: Send Retrieval Requests to: o Business Location o Corp/Legal Location Send Merchant Monthly Statement to: o Business Location o Corp/Legal Location o Individual/Sole Proprietorship: State in which Certificate of ASSUMED NAME FILED: STATE: o CORPORATION CHAPTER S, C STATE: o TAX EXEMPT ORGANIZATION (501C) State: o INTERNATIONAL ORGANIZATION Location Filed: o GOVERNMENT (Federal, State, Local) o LIMITED LIABILITY COMPANY State Filed: o MEDICAL OR LEGAL CORPORATION STATE: o ASSOCIATION/ESTATE/TRUST State Filed o PARTNERSHIP State Filed: Name (as it appears on your income tax return): FEDERAL TAX ID # (as it appears on your income tax return) o I certify that I am a foreign entity/ nonresident alien (If Checked please attach IRS Form W-8) NOTE: Failure to provide accurate information may result in a withholding of merchant funding per IRS regulations (See part IV, Section A.4 of your Program Guide for further information.) SIC/MCC: Detailed Explanation of Type of Merchandise, Products or Services Sold: 2. ADDITIONAL CREDIT / SITE SURVEY INFORMATION - ALL MERCHANTS Are you using a vendor? o Yes o No If yes please supply a copy of Vendor s report. 1. Zone: o Business District o Industrial o Residential 2. Location: o Mall o Office o Home o Shopping Area o Mixed o Apartment o Isolated 3. How many employees: 4. How many registers / terminals: 5. Is proper license visible? o Yes No,explain: 6. Where is the merchant name displayed at the site? o Window o Door o Store Front 7. Merchant Occupies: o Ground Floor o Other: 8. # Of Floors/Levels: o 1 o 2-4 o 5-10 o Remaining Floor(s) Occupied by: o Residential o Commercial o Combination 10. Approximate Square Footage: o o o 501-2,000 o 2,001 plus 11. Are customers required to leave a deposit? o No o Yes If Yes, % of deposit required: % 12. Return Policy: o Full Refund o Exchange Only o None 13. Do you have a refund policy for MC/Visa/Discover Network/American Express OnePoint Sales? o Yes o No If yes, check one. o Exchange o Store Credit o MC/Visa/Discover Network Credit o American Express OnePoint Credit? If MC/Visa/Discover Network/American Express One Point Credit within how many days do you submit credit transactions? o 0-3 o 4-7 o 8-14 o Over Advertising Method (Attach at least one): o Catalog o Brochure o Direct Mail o TV/Radio o Internet o Phone o Newspaper/Journals o Other Marketing Materials required for Mail Order, B to B, Internet over $1 Million in annual volume. Attach Web Page for Internet Merchant. 15. Your Previous Processor: 16. Check Reason For Leaving: o Rate o Service o Terminated Date: o Other: Mail/Telephone Order/ Business to Business / Internet Information (All questions must be answered) 1. What % of total sales represent business to business (vs business to consumer): Business to Business % + Business to Consumer % = 100% (total sales) 2. What % of bankcard sales represent business to business (vs business to consumer): Business to Business % + Business to Consumer % = 100% (total sales) 3. What is the time frame from transaction to delivery? (% of orders delivered in): 0-7 days % days % days % + over 30 days % = 100% 4. MC / Visa / Discover Network / American Express OnePoint sales are deposited (check one): o Date of order o Date of delivery o Other (specify) 5. Who performs product / service fulfillment? o Direct o Vendor o Other If vendor, add Name: Address: City/State/Zip: Please describe how the transaction works, from order taking to merchant fulfillment (attach additional sheet if necessary): 6. Does any of your cardholder billing involve automatic renewals or recurring transactions (i.e. cardholder authorizes initial sale only)? o Yes o No Phone: Blackstone Merchant Services is a registered ISO/MSP of Wells Fargo Bank, N.A., Walnut Creek, CA Merchant Initials:
2 DBA Name: Merchant #: Page 2 of 4 Blackstone COMPANY HISTORY Blackstone1605(ia) Date Business Started: Prior Bankruptcies? o No o Yes o Business and / or o Personal TRADE REFERENCE 1 TRADE REFERENCE 2 Vendor Name: Vendor Name: Address: Address: City: State: Zip: City: State: Zip: Contact Name: Contact Phone #: Customer Service Ph # Vendor Acct. #: Contact Telephone #: Vendor Acct. #: 4. OWNER / PARTNER / OFFICER OWNER / PARTNER / OFFICER 1 OWNER / PARTNER / OFFICER 2 Name: (First, Mi, Last) % Ownership Name: (First, Mi, Last) % Ownership Title: Title: Home Address: (No P.O. Box) Home Address: (No P.O. Box) City State: Zip: Country: City: State: Zip: Country: Telephone #: Social Security #: Telephone #: Social Security #: D.O.B.: DL #: State: D.O.B.: DL #: State: 5. SETTLEMENT INFORMATION Deposit Bank: Bank Contact #: Transit / ABA #: Deposit Account #: ACH Detail Flag: o Individual o Combined o Separate (defaults to combined if option not selected) 6. EQUIPMENT/THIRD PARTY INFORMATION Network (Front End): o Omaha o North o Nashville o BuyPass Do you use any third party to store process or transmit cardholder data? o Yes o No If yes, give name/address: Please identity any Software used for storing, transmitting, or processing Card Transactions or Authorization Requests: INTERNET GATEWAY: o Blackstone Gateway Other: Wireless Network: PC/Internet Software Quantity o Purchase $ o Lease o Reprogram Terminal Model o Pax S80 Other Quantity o Purchase $ o Lease o Reprogram POS System o HioPOS Other (See Service Agreement) o Purchase $ o Lease o Reprogram PIN Pad Quantity o Purchase $ o Lease o Reprogram LEASE COMPANY: (04) First Data Global Leasing Lease Term: Mos. Annual Tax Handling Fee: Total Monthly Lease Charge: w/o taxes, late fees, or other charges that may apply See Lease Agreement in Program Guide for details. This is a non-cancelable lease for the full term indicated. Address: City: State: Zip: Attention: 7. GRID INFORMATION - INTERNAL USE ONLY Authorization Grid ID# Tiered Discount Grid# User Defined Grid# 8. TRANSACTION INFORMATION FINANCIAL DATA WHERE IS SALE TRANSACTED? (Must = 100%) Gross YEARLY Sales Vol. (Cash + Credit + Debit + Check) Average MC/Visa/Discover Network Ticket (Estimate if Never Processed in Past) Store Front/Swiped % Average YEARLY MC/Visa/Discover Volume Avg. Pin Debit Ticket ecommerce % Average YEARLY Pin Debit Volume Avg. American Express OnePoint Ticket Mail/ Telephone Order % Average YEARLY American Express One Point Volume Highest Ticket Amount Seasonal? o No o Yes High Volume Months Open: TOTAL 100 % Blackstone Merchant Services is a registered ISO/MSP of Wells Fargo Bank, N.A., Walnut Creek, CA Merchant Initials:
3 DBA Name: Merchant #: Page 3 of 4 Blackstone SERVICE FEE SCHEDULE Blackstone1605(ia) MasterCard, Visa and Discover Network Authorization & Capture Fee: (Per Item) Authorization & Capture Transaction Fees Miscellaneous Fees Dues & Assessments Chargeback Fee $ (Per Item) Retrieval Fee (12B Letter) (Per Item) Return Trans. Fee (Per Item) Refer to Program Guide Setup Fee: o ACH o Check _ Batch Fee (Per Item) Early Termination Fee $ Section A.3 EBT Food Stamps $ (Per Item) #: EBT Cash Benefits $ (Per Item) Other: Annual Support Fee $ Wireless Setup Fee: Check Setup Fee: Gift Card Setup Fee: $ Visa Processing Fees MasterCard Processing Fees Discover Processing Fees 3 Pass Visa ACQ ISA Fee: 3 Pass Visa Acquirer Processing Fee. 3 Pass Visa Misuse of Authorization Fee. 3 Pass Zero Floor Limit Fee. 3 Pass Visa International Acquirer Fee 3 Pass Visa International Acquirer Network Fee (FANF). 3 Pass Visa International Integrity Fee. 3 Pass MC Acquirer Support Fee. 3 Pass MC Cross Border Fee. 3 Pass MC National Acquirer. 3 Brand Usage (NABU) Fee. 3 MC Processing Integrity Fee. Accept all MasterCard, Visa and Discover Network Transactions (presumed, unless any selections below are checked) 3 Pass Discover International Processing Fee. 3 Pass Discover International Service Fee. 3 Pass Discover Data Usage Charge. MasterCard Acceptance Visa Acceptance Discover Network Acceptance AMEX OnePoint Acceptance o Accept MC Credit Transaction only o Accept Visa Credit Transactions only o Accept MC Non-PIN Debit Trans. only o Accept Visa Non-PIN Debit Trans. only o Accept Discover Network Credit Transaction only o Accept Discover Network Non-PIN Debit Transaction only See Section 1.9 of the Program Guide for details regarding limited acceptance. o Discount Collected o Daily o Monthly o Accept AMEX Credit Transaction only TransArmor Auth Fee Voice Authorization Fee Electronic AVS Fee Voice AVS Fee ARU Fee Monthly Statement Fee Monthly Minimum Fee Reg. Product Fee Customer Service Fee Debit Access Fee PCI Fee Monthly Fees eids Online Chargeback Fee $ (Per Item) $ 1.00 (Per Item) $.05 (Per Item) $ 2.50 (Per Item) $.75 (Per Item) 4.95 NO COST NO COST 4.95 Portfolio Mgr Fee o Yes o No Wireless Fee Website Usage IVR Usage Other: Non PCI Compliance Fee TIN/TFN Invalid n Tiered Discount Fees (Based on Gross Sales Volume) n ERR PIN Debit Yes No Discount Discount Non-Qual Fees o Pass Through Debit Network Fees Only If Applicable MC/Visa/Discover Network Qual Credit % MC/Visa/Discover Qual Credit % % Other Item Rate (per item) MC/Visa/Discover Network Mid-Qual Credit % MC/Visa/Discover Qual Debit % % Other Volume Percent (per item) MC/Visa/Discover Network Non-Qual Credit % % % MC/Visa/Discover Network Qual Debit % n Pass Through Interchange - Includes Dues and Assessments Fleet MC/Visa/Discover Network Mid-Qual Debit % Plus Discount Wright Express: MC/Visa/Discover Network Non-Qual Debit % (Based on Gross Sales Volume) Other Item Rate (per item) MC/Visa/Discover Network Regulated Debit % MC/Visa/Discover Qual Credit % Voyager: American Express Card Acceptance MC/Visa/Discover Qual Debit % Qual % (per item) TeleCheck Would you like to process American Express? o Yes o No Existing Amex Merchant Account Number o American Express OnePoint/Full Service (EDC) or o American Express ESA/Passthrough* AMEX Discount Rate % Transaction Fee $ AMEX Prepaid Discount Rate % Transaction Fee $ *American Express will charge a flat fee of $ or a discount rate to the merchant. 0.30% downgrade will be charged by American Express for transactions whenever a CNP or Card Not Present Charge occurs including Prepaid Cards. CNP means a Charge for which the Card is not presented at the point of purchase (e.g., Charges by mail, telephone, fax or the Internet). NOTE: The CNP Fee is applicable to transactions made on all American Express Cards, including Prepaid Cards for Retail, Restaurant, and Travel Agencies/Tour Operators keyentered programs. An Inbound fee of.40% will be applied to any charge made using a card, including Prepaid Cards, issued by an issuer located outside of the United States (the United States does not include Puerto Rico, the U.S. Virgin Islands and other U.S. territories and possessions) except MCC 7032, 8211, 8351, and 8220 card transactions. o Split Dial o License # o MICR o ECA Warranty o Mail Order o Hold Check o Paper Warranty o C.O.D. SE Number _ TeleCheck Rates & Fees Yes No Inquiry Rate % Stmt/Processing Fee 5.00 Dec. Risk Surcharge.10 % ACH Processing Fee Per TXN Fee Client Requested Operator Call (CROC) Minimum Monthly Fee (Per Location) ECA Chargeback Fee 5.00 (only charged when entitled with TeleCheck) See Agreement for definitions, warranty requirements and any additional fees. Blackstone Merchant Services, LLC is a registered ISO/MSP of Wells Fargo Bank, N.A., Walnut Creek, CA Merchant Initials:
4 DBA Name: Merchant #: Page 4 of 4 Blackstone SIGNATURE (S) Blackstone1605(ia) 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 Blackstone1605) and Confirmation Page, which is part of this Merchant Processing Application (consisting of Sections 1-10), and by this reference incorporated herein. Client hereby consents to receiving commercial electronic 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 transactions via mail, telephone or Internet order. However, if your Application is approved based upon contrary information stated in Section 8,Transaction Information section above, you are authorized to accept transactions in accordance with the percentages indicated in that section. This signature page also serves as a signature page to the Equipment Lease Agreement, TeleCheck Services Agreement, and the American Express Card Acceptance Agreement appearing in the Third Party Section of the Program Guide, if selected, the undersigned Client being the Lessee for purposes of such Equipment Lease Agreement and/or You and Your for the purposes of the TeleCheck Services Agreement and American Express Card Acceptance Agreement. Client authorizes Blackstone Merchant Services ( BMS ) and Wells Fargo Bank, N.A. ( Bank ) and their Affiliates to investigate the references, statements and other data contained herein and to obtain additional information from credit bureaus and other lawful sources, including persons and companies named in this Merchant Processing Application. Client authorizes BMS and BANK and their Affiliates (a) to procure information from any consumer reporting agency bearing his/her personal credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living, and (b) to contact all previous employers, personal references and educational institutions. Each of the undersigned authorizes us and our Affiliates to provide amongst each other the information contained in this Merchant Processing Application and Agreement and any information received from all references, including banks and consumer reporting agencies. It is our policy to obtain certain information in order to verify your identity while processing your account application. 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 Blackstone Merchant Services (BMS) 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 BMS and AXP and AXP s 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 on me from consumer reporting agencies for marketing and administrative purposes. I am able to read and understand 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 BMS 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 not qualify for the BMS servicing program that the entity may be enrolled in AXP s standard Card acceptance program, and the entity may terminate the Agreement. By accepting the 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. Client authorizes BMS 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 provided herein are correct. Client agrees to all the terms of this Merchant Processing Application and Agreement. This Merchant Processing Application and Agreement shall not take effect until Client has been approved and this Agreement has been accepted by BMS and Bank. Client s Business Principal/Officer: Signature X Title Print Name of Signer Date Signature X Title Print Name of Signer Date Personal Guarantee: In exchange for Blackstone Merchant Services Corporation,Wells Fargo Bank, N.A., American Express and TeleCheck Services, Inc. (the Guaranteed Parties) acceptance of, as applicable, the Agreement, and/or the Equipment Lease 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 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. Personal Guarantee Signature X Print Name: Date Personal Guarantee Signature X Print Name: Date Telecheck ACH Authorization: ACH Debit and Credit Authorization: Client authorizes its Financial Institution to pay and charge to its account the amount(s) due TeleCheck under this TeleCheck Agreement and to accept all credits and debits made to its account by TeleCheck via electronic funds transfer in connection with TeleCheck s services under this TeleCheck Agreement.This authorization shall remain in effect until (30) thirty days after revoked in writing. Signature X Authorized Signature on TeleCheck Account for ACH Print Name: Date FOR INTERNAL USE ONLY Accepted By Blackstone Merchant Services, Inc. Wells Fargo Bank, N.A., Walnut Creek, CA Personal Guarantee Signature X Title Date Signature X Title Date Blackstone Merchant Services is a registered ISO/MSP of Wells Fargo Bank, N.A., Walnut Creek, CA
5 Blackstone1605 PROCESSOR INFORMATION: PART PART IV: I: CONFIRMATION PAGE Name: Blackstone Merchant Services, Inc. Address: NW 34th Street, Miami, FL URL: Customer Service #: Please read the Program Guide in its entirety. It describes the terms under which we will provide merchant processing Services to you. From time to time you may have questions regarding the contents of your Agreement with Bank and/or Processor or the contents of your Agreement with TeleCheck. The following information summarizes portions of your Agreement in order to assist you in answering some of the questions we are most commonly asked. 1. Your Discount Rates are assessed on transactions that qualify for certain reduced interchange rates imposed by MasterCard and Visa. Any transac tions that fail to qualify for these reduced rates will be charged an additional fee (see Section 18 of the Pro gram Guide). 2. We may debit your bank account (also referred to as your Settlement 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 dis cussion regarding Chargebacks see Section 10 of Card Process ing Operating Guide or see the applicable provisions of the TeleCheck Services Agreement. 4. If you dispute any charge or funding, you must notify us within 60 days of the date of the statement where the charge or funding appears for Card Pro cess ing or within 30 days of the date of a TeleCheck transaction. 5. The Agreement limits our liability to you. For a detailed descrip - tion of the limitation of liability see Section 20 of the Card Processing General Terms; or Sec tion 1.14 of the Tele Check Services Agree ment. 6. We have assumed certain risks by agreeing to provide you with Card processing or check services. Accordingly, we may take certain actions to mitigate our risk, including termination of the Agreement, and/or hold monies otherwise payable to you (see Card Processing General Terms in Section 23, Term; Events of Default and Section 24, Reserve Account; Security Interest), (see TeleCheck Services Agree ment in Sections 1.1, 1.3.2, 1.3.9, 1.6), under cer tain circumstances. 7. By executing this Agreement with us you are authorizing us and our Affiliates to obtain financial and credit information regarding your busi ness and the signers and guar antors of the Agreement until all your obliga tions to us and our Affiliates are satisfied. 8. The Agreement contains a provision that in the event you termi nate the Agree ment early, you will be responsible for the payment of an early termi - nation fee as set forth in Part IV, A.3 under Additional Fee Infor mation and Section 1 of the TeleCheck Services Agreement. 9. If you lease equipment from Processor, it is important that you review Section 1 in Third Party Agreements. Bank is not a party to this Agreement. THIS IS A NON-CANCEL ABLE LEASE FOR THE FULL TERM INDICATED. 10. Card Organization Disclosure Visa and MasterCard Member Bank Information: Wells Fargo Bank N.A. The Bank s mailing address is 1200 Montego, Walnut Creek, CA 94598, and its phone number is (925) Important Member Bank Responsibilities: a) The Bank is the only entity approved to extend acceptance of Card Organization 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. Important Merchant Responsibilities: a) Ensure compliance with Cardholder data security and storage requirements. b) Maintain fraud and Chargebacks below Card Organization thresholds. c) Review and understand the terms of the Merchant Agreement. d) Comply with Card Organization rules. e) Retain a signed copy of this Disclosure Page. f) You may download Visa Regulations from Visa s website at: g) You may download MasterCard Regulations from MasterCard s website at: Print Client s Business Legal Name: By its signature below, Client acknowledges that it has received (either in person, by facsimile, or by electronic transmission) the complete Program Guide [version Blackstone1605] con sist ing 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 Agree ment. Upon receipt of a signed facsimile or original of this Confirmation Page by us, Client s Application will be processed. Client understands that a copy of the Program Guide is also available for downloading from the Internet at: NO ALTERATIONS OR STRIKE-OUTS TO THE AGREEMENT WILL BE ACCEPTED. Client s Business Principal: Signature (Please sign below): X Title Date Please Print Name of Signer Blackstone1605
6 Services Terminal Setup Form Merchant DBA Blk MID Business Information Retail Retail With Tips Restaurant Please Select the Business Type General Parameters Yes No Password Protection Yes No 6 Digits Password External Pin Pad Sales Debit Processing Returns EBT Processing Voids Prompt for Invoice Number During the Sale Settlement (Closing) Prompt for Customer Code During the Sale Reprint Receipts Allow Manual Transactions Reports Menu Debit Cash Back EBT Balance Inquiry EBT Cash Back Open Batch Review Last 4# s of the card, AVS & CVV2 are mandatory prompts Authorizations Tips & Clerks Yes No Others Parameters Yes No Fill Only if Yes Tip Processing Auto Close Time? Prompt for Clerk or Server Number Apply Tax Over Sale Tax%? Prompt for Tip at the Moment of the Sale Allow Closing with Unadjusted Tips NOTE: The TAX will increase the transaction amount NOTE: Auto Close is not recommended if you work with Tips Additional Services Yes No Communication Mode Select Only One Store Gift Cards Wireless Calling Cards & Cell Phone Recharges Phone Line (No V/IP - No Magic Jack) Check Processing (TeleCheck) High Speed Internet (IP) Prefix (Please fill this area Only if your communication mode is Phone Line) Some phone systems require a Prefix Digit to make a phone call (Usually 9 or 0) Any Prefix Digit? Other Requirements Not Listed in this Form Blackstone Representative Printed Name: Signature Rev
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