NetSource Commerce Payment Gateway Sign Up Form Page 1 of 6

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1 NetSource Commerce Payment Gateway Sign Up Form Page 1 of 6 Who should use this form This document is for merchants that wish to sign up for the NetSource Commerce Payment Gateway. For more information on the Gateway, visit: Use this document if you already have a merchant account. You will be asked to provide your merchant account information below. If you do not have a merchant account, just contact us at [email protected] and we will get you setup with a compatible, inexpensive merchant account. Required steps To sign up for the NetSource Commerce Payment Gateway: 1. Fill out, print, and sign this form 2. Make sure to enter correct merchant account information in the corresponding area 3. Attach a company voided check 4. Fax everything to (352) Attn: Gateway or scan & to [email protected]

2 NetSource Commerce Payment Gateway Sign Up Form Company Information Company Name Company Address City State Phone ZIP Fax Web Business Type [ ] INC [ ] LLC [ ] Partnership [ ] Sole Proprietor [ ] Non-Profit Established (mm/yy) Tax ID (EIN) or SSN Goods/Services Sold Classification [ ] E-Commerce [ ] MOTO (Mail Order) [ ] Retail Currency We will be using the NetSource Commerce Gateway with [ ] ProductCart [ ] Other (please specify): Contact information Contact Name Contact

3 Contact phone(s)

4 Current Monthly Fees The current monthly fees for services are listed below. These fees are subject to changes at any time without notice. A list of current fees can always be found at Merchant Account Setup $0.00 Merchant Account Monthly $25.00* Month *includes PCI Compliant Credit Card Vault Per Transaction Fee.12 per Transaction Vault Record Add/Edit/Remove.10 per vault transaction Additional services Contact us if you need more information about any of these services [ ] Electronic Checks - $49 setup fee, $20/month, plus $0.50 per transaction [ ] Mobile Payments - From your iphone, ipad, etc.: $15/month. Encrypted card reader not included. [ ] ispyfraud - Advanced fraud detection tools. $10/month + $0.11/transaction [ ] CertifyPCI - PCI compliance self-assessment wizard & network scanning - $249/year [ ] Data Decryption - Set Up Fee: $ Monthly Fee: $ Per Transaction Fee: $0.15 Signature Name Title Signature Date

5 Merchant Processing Account Information Look at any statement received from your merchant account provider. This is the company to which you pay merchant processing fees (a % of all of your credit card transactions). On the statement, you should find the name of your merchant processing network, and related information that you will need to provide. If you can t locate the information, contact your merchant account provider. If you don t have a merchant account, [email protected], and we ll be happy to help you get setup. Indicate your merchant processing platform, and merchant account identifiers. [ ] CardWords Terminal ID: Acquirer BIN: [ ] ELAVON Bank Number: Terminal ID: Merchant ID: [ ] Electronic Payment Exchange (EPX) Customer Merchant Number: DBA (Doing Business As) Number: Terminal Number: Merchant Authorization Code: [ ] First Data Merchant Services (FDMS) Nashville Merchant ID (MID): Terminal ID: [ ] First Data Merchant Services (FDMS) Omaha Merchant Number:

6 [ ] Global Payments - East Merchant ID (MID): Bank ID: [ ] Global Payments - Canada Merchant ID (MID): Bank ID: [ ] Interlink Merchant User Name: Merchant Password: [ ] Merchant e-solutions (MeS) Trident Merchant Number (12 digits): Acquirer BIN (6 digits): Store Number (4 digits): Terminal Number (4 digits): Merchant Category (4 digits): Location Number (5 digits): Terminal ID (8 digits): Agent Bank (6 digits): Agent Chain (6 digits): [ ] Paymentech Salem Division Number (up to 10 digits): Aggregator Indicator:

7 [ ] Paymentech Tampa PNS Merchant Number: Terminal Number: [ ] TSYS/Vital Merchant Number (12 digits): Acquirer BIN (6 digits): Store Number (4 digits): Terminal Number (4 digits): Merchant Category (4 digits): Location Number (5 digits): Vital Number (8 digits): Agent Bank (6 digits): Agent Chain (6 digits):