MERCHANT PROCESSING APPLICATION AND AGREEMENT

Transcription

1 Sales Rep App Date: MERCHANT PROCESSING APPLICATION AND AGREEMENT PPS GENERAL INFORMATION 2. PPS1210 BUSINESS LOCATION INFORMATION 3. BUSINESS STRUCTURE Pg 1 of 4 Client s Business Name (Doing Business As) Client s Corporate/Legal Name (Must match IRS income tax filing) Location Address Corporate Address (if Different than Location) City State Zip City State Zip Location Phone Location Fax Contact Name Contact Phone Customer Service Phone Breech? Business Website Address No Multiple locations? Y or N Prior Security Yes If Yes, enter # of locations Business D&B# Fed Tax ID # (Must match IRS income tax filing) Date Business Started Length Current Ownership Additional Location to existing MID Send retrieval / chargeback requests to Send monthly merchant statements to Corporate Address Location Address Corporate Address Location Address I certify that I am a foreign entity / nonresident alien. (If checked, please attach IRS Form W-8.) Sole Prop Partnership LLC/LLP C Corp S Corp Govt. (Local/State/Federal) 501c/Tax Ex. State Filing: NOTE: Failure to provide accurate information may result in a withholding of merchant funding per IRS regulations. (See Section III, Part A.3 of your Program Guide for further information.) 4. OWNERS / PARTNERS / OFFICERS 5. TRADE REFERENCE OWNER / PARTNER /OFFICER 1 OWNER / PARTNER /OFFICER 2 TRADE REFERENCE Name Name Business Name Title % Ownership Title % Ownership Business Address Home Address Home Address City State Zip City State Zip City State Zip Contact Telephone Telephone Telephone Address Address Account # Social Security # Birth Date Social Security # Birth Date Prior Bankruptcies? No Yes Business and/or Personal Date Discharged: 6. NATURE OF BUSINESS 7. TRANSACTION INFORMATION Business Type: Retail Restaurant Mail / Telephone Order Internet Lodging Supermarket Government Petroleum Utilities Healthcare Education QSR Charity/Non Profit B2B Other Requested Monthly Payment Card Volume $ Card Present Swiped % Sales to Consumers % Requested Average Payment Card Ticket $ Card Present Not Swiped % Sales to Business % Requested Highest Payment Card Ticket $ MOTO % Sales to Government % Seasonal Merchant? Yes No (circle closed months if yes) J F M A M J J A S O N D Internet (ecommerce) % Days to Delivery Prior Processor Description of products or services sold Describe your return policy 8. BANKING ACCOUNT INFORMATION Deposit Bank Name Routing# Account# Bank Phone Checking Savings Combined Batch ACH Individual Batch ACH

2 9. SERVICE ACCEPTANCE AND FEE SCHEDULE Pg. 2 of 4 Select all card types you wish to accept (See Section 1.9 of the Program Guide for details regarding limited acceptance) xx Visa Credit xx MC Credit xx Visa Non-PIN Debit xx MC Non-PIN Debit xx Discover Network American Express Pin Debit Select V/MC/Discover Network Discount Plan: (Based on Gross Sales Volume) Tiered Basic Pass Through I/C PinDebit Discount Plan: Pin Debit Network Fee Pass-through Enhanced Recover Reduction (ERR) Requested Discount Payment Method: Daily Assessments: Included xxx Bill Separately (If Pass Through I/C Assessments MUST Bill Seperately) XX Monthly QUALIFICATION DISC. FEE (%) PER ITEM ($) DISCOUNT FEES QUALIFICATION DISC. FEE (%) PER ITEM ($) QUALIFICATION DISC. FEE (%) MASTERCARD VISA DISCOVER NETWORK Credit Qualified % $ Credit Qualified % $ Credit Qualified % $ Credit Mid-Qual Qual +.50% $ Credit Mid-Qual Qual +.50% $ Credit Mid-Qual Qual +.50% $ Credit Non-Qual Qual % $ Credit Non-Qual Qual % $ Credit Non-Qual Qual % $ CheckCard Qual % $ CheckCard Qual % $ CheckCard Qual % $ CheckCard Mid-Qual Qual +.50% $ CheckCard Mid-Qual Qual +.50% $ CheckCard Mid-Qual Qual +.50% $ CheckCard Non-Qual Qual % $ CheckCard Non-Qual Qual % $ CheckCard Non-Qual Qual % $ Pass Through IC % $ Pass Through IC % $ Pass Through IC % $ ERR Mark UP % $ ERR Mark Up % $ ERR Mark Up % $ All applicable Association fees will be passed through to the merchant at the applicable costs assigned by Voyager % the Association. Fees include but are not limited to Visa s APF, Misuse of Authorization Fee, Zero Floor Limit Fee, Acquirer ISA Fee, and MasterCard s NABU Fee, Acquirer Support Fee, Cross Border Fee, and Discover IPF, ISF, Data Usage fee, et al. American Express One Point Discount (choose one) B2B Industry 2.89% plus $0.15 Transaction Fee* Discount Program Type One Point ESA*** Education 2.50% Fast Food Restaurant 3.50% Order New Use Existing Independent Gas Station 3.25% Existing SE # CAP # Lodging 3.50% Mail Order & Internet 3.50% *Fee to be applied by American Express Office-based Healthcare 2.55% Other Transportation 3.50% **0.30% downgrade will be charged for transactions whenever a CNP (Card not Restaurant** 3.50% plus $0.05 Transaction Fee* Present) charge occurs. CNP means a charge for which the card is not Retail** 2.89% plus $0.10 Transaction Fee* presented at the point of purchase (e.g. charges by mail, telephone, fax or Services, Wholesale & All Other 2.89% plus $0.15 Transaction Fee* Internet). Supermarket 2.30% Telecommunications 3.50% Authorization Fees ***FOR ESA ONLY - Monthly flat fee of $7.95 or Discount Rate may apply. Monthly Fees Visa/MC/Discover Network $0.20 Electronic AVS $0.05 Monthly Minimum $25.00 Industry Compliance $7.95 Amex/ Fleet/Other $0.20 Voice Auth $1.00 Wireless Fee per terminal (if applicable) Pin Debit Authorization $0.10 Voice AVS $3.00 PIN Debit Fee $0.00 $20.00 Monthly Service Fee EBT Authorization $0.15 Industry Non-Compliance up to $14.95 (if applicable per Section 4.8 of the Merchant Program Guide) Miscellaneous Fees MX Merchant Fees Sales Transaction Fee (All Card Types) $0.00 Chargeback Fee $30.00 MX Merchant Monthly Fee (Circle one Program) $9.99 PER ITEM ($) Return Transaction Fee (All Card Types) $0.20 Batch Fee $0.30 ACH Reject Fee $25.00 (Per Occurrence) Retrieval Fee $12.00 Annual Fee $ Wireless Set up Fee $39.99 (Billed Separately by Cost Plus) $0.00 Reporting $5.00 Basic $10.00 Plus $15.00 premium $40.00 Enterprise MX Gateway Transaction Fee $0.05 Retail $0.10 MOTO/Internet Bill to xx Statement Separately Credit Card In the event that this Agreement is terminated early, Merchant will be responsible for the payment of a $ Early Termination Fee in accordance with Part III, Section A.3 of the Merchant Program Guide.

3 10. Other Card Types Page 3 of 4 Accept EBT Accept EBT Cash Benefit Yes No Yes No EBT # (Number(s) must be obtained through the state department of agriculture) 11a. EQUIPMENT / PROCESSING METHOD Order Voyager Yes No Order WEX Yes No (Must attach Wright Express application and Debranding letter with app copy) Application Type: Retail Retail w/ tip MOTO Restaurant w/ tip Quick Serve Restaurant (no tip) Hotel Auto Rental Terminal Features N YES NO YES NO YES O Fraud Check (last 4-digits) Purchasing Card Invoice # / Purch order # AVS + CVV2 Server / Clerk # Auto Close? Y N If yes, time? IP Connection? Yes No If yes, Terminal Serial Special Requests (Multi-Mid, Dial 9, etc): Wireless? Yes No Wireless Info: MAN/Serial SIM Card Number TYPE OF EQUIPMENT PRODUCT NAME QUANTITY DEPLOYMENT Terminal Pinpad Printer VAR* Existing Agent New Order (attach order form) Terminal Pinpad Printer VAR* Existing Agent New Order (attach order form) Terminal Pinpad Printer VAR* Existing Agent New Order (attach order form) Terminal Pinpad Printer VAR* Existing Agent New Order (attach order form) *Manufacturer/product/version of PC/Internet software: Prior Security Breach Yes No Do you use any third party to store, process or transmit cardholder data? Yes No? If yes, name/address:. ORDER LEASE Y. N. Lease Company: 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 for details. This is a NON-CANCELABLE lease for the full term indicated (Client s Initials: ) 11b. CARD NOT PRESENT INFORMATION If you process more than 30% of your bankcard transactions, or volume, without swiping and/or examining the credit card, please complete this section and provide the information requested. 1. Please submit your Product catalog; brochures; promotional materials; a current price list; and a copy of your service agreement with card holder if applicable. If on the Internet, please include screen-prints of your website address if your site is not yet active. 2. If Internet please check your type of business: Web Hosting Domain Registration Web Page Design Auction Internet Service Gateway Selling Digital Service Advertisement Selling Hard Goods Other If using the Internet, list encryption method, vendor, and controls used to secure transaction information: 3. How will the product be advertised or promoted? 4. Billing Methods: (Check all that Apply) Monthly - % Yearly - % Quarterly - % One Time - % Hourly - % 5. List the name(s) and address(es) of the vendors from which supplies are purchased. 6. Who performs product/service fulfillment? If direct from vendor please provide Vendor Name, address and phone number in full. 7. Please describe how a sale takes place from beginning of order until completion of fulfillment PPPPP

4 12a. SITE INSPECTION (Completed by Sales Agent) Page 4 of 4 I have personally conducted a Site Inspection for this merchant, visually inspected the merchant s inventory (if applicable), verified the merchant s payment application is PABP (Payment Application Best Practices) validated (if applicable), and represent that the information in this merchant application is accurate, as to the best of my knowledge. I am subject to criminal penalties and/or financial losses for false or misleading information. Sales Agent Name: (printed) 12b. Annontation Signature X 13 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 PPS1409) and Confirmation Page, which is part of this Merchant Processing Application (consisting of Sections 1-13) and by this reference incorporated herein. Client further agrees that Client will nott 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 7, 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 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 American Express Card Acceptance Agreement. Client authorizes PRIORITY PAYMENT SYSTEMS ( PRIORITY ) and Wells Fargo Bank, N.A. ( BANK ) and their respective agents 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 names in this Merchant Processing Application. Client authorizes PRIORITY and BANK and their respective agents (a) to procure information form 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 also 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. If the Application is approved, each of the undersigned also authorizes us to obtain subsequent consumer reports in connection with the maintenance, updating, renewal or extension of the Agreement. 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 PRIORITY 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, and disclose such information to their agent, subcontractors, Affiliates and other parties for any purpose permitted by law. I authorize and direct PRIORITY and AXP and AXP agents and Affiliates to inform me directly, or through the entity above, 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 fro marketing and administrative purposes. I understand that upon AXP s approval of the Application, the entity will be the Agreement and materials welcoming it, either to AXP s program for PRIORITY to perform services for AXP or in AXP s standard Card acceptance program, which has different servicing terms (e.g., different sppeds of pay). I understand that if the entity does not qualify for the PRIORITY servicing program, 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 PRIORITY and BANK and their affiliates to debit Client s designated bank account via Automated Clearing House (ACH) for costs associated with the 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. 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 PRIORITY 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 The undersigned guarantees to PRIORITY and BANK the performance of the Agreement, and First Data Lease if applicable, and any addendum thereto by Client, including payment of all sums due and owing and costs associated with the enforcement of the terms thereof. PRIORITY and BANK shall not be required to first proceed against the Client or enforce any other remedy before proceeding against the undersigned individual. This is a continuing guarantee and shall not be discharged or affected by the death of the undersigned and shall bind the heirs, administrators, representatives and assigns and be enforced by or for the benefit of any successor of PRIORITY or BANK. The term of this guarantee shall be for the duration of the Merchant Processing Application and Agreement and any addendum thereto and shall guarantee all obligations which may arise in connection with my activities during the term thereof through enforcement shall be sought subsequent to any termination. Personal Guarantee Signature X Print Name: Date Personal Guarantee Signature X Print Name: Date Accepted By Priority Payment Systems, LLC Wells Fargo Bank, NA P.O. BOX 246, Alpharetta, GA Montego Way, Walnut Creek, CA Signature X Title Date Signature X Title Date

5 PPS1409(ia) PROCESSOR INFORMATION: PART IV: CONFIRMATION PAGE Name: Priority Payment Systems Address: P.O. Box 246, Alpharetta, GA 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. 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 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. 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. 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. 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), 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 III, A.3 under Additional Fee Infor mation. 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. For questions regarding your Merchant Processing Application and Agreement, please contact Customer Service at , and / or refer to Important Phone Numbers on the Additional Impor tant Information Page, Part III, Section A Card Organization Disclosure Visa and MasterCard Member Bank Information: Wells Fargo Bank N.A. The Bank s mailing address is 1200 Montego Way, 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 PPS1409(ia)] con sist ing of 35 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 PROGRAM GUIDE WILL BE ACCEPTED. Client s Business Principal: Signature (Please sign below): X Title Date Please Print Name of Signer PPS1409(ia) 35

6 7799 Roswell Rd. Sandy Springs, GA Legal Name: MERCHANT PROCESSING AGREEMENT ADDENDUM DBA: Sales Agent: Date: Receipt of Funds: if applicable QTY EQUIPMENT DESCRIPTION OR REPROGRAM INSTRUCTIONS Each Total 1 Manual Imprinter (Merchant must initial waiver if not purchasing) $ $ Check One: Analog IP Contact Info: Hours of Operation for Install: Contact Ph No: Cost Plus Match Guarantee: Cost Plus Processing Guarantees to match any competitor's pricing when confirmed by an executive member or we will pay your ETF for you to switch processors. Subtotal: This addendum (the Addendum ) to the Merchant Processing Agreement ( Agreement ) is entered into between Cost plus Processing ( CPP ) and the undersigned merchant ( Merchant ) as of the recorded date below. In consideration of the mutual promises contained herein and the consideration contained in the Agreement, the sufficiency of which is hereby acknowledged, the parties hereto agree as follows: Merchant hereby authorizes CPP or any other authorized partner such as, EPN, Authorize.Net, Etc... to initiate and/or transmit automatic credit and/or debit entries, via the automated clearing house network ( ACH ), to the Account and Depository identified in the attached voided check (hereafter, Merchant s Account ), and listed below. Said authorization includes, but is not limited to, the initiation and transmission of such entries, requests, or orders as may be necessary to charge Merchant s Account for any fees or other amounts payable by Merchant to CPP or any other partners in pursuant to the terms of the Agreement. Merchant also agrees to a one time application fee of Fifty dollars ($50) to be billed through said Account listed below and understands by initialing the bottom portion of said agreement. Merchant will also be charged a fee of nine dollars and ninety-nine cents ($9.99) per month for warranty of all equipment and supplies, which shall be collected electronically on the third day of each month (commencing on the third month for merchants leasing equipment). All loaner equipment requires warranty program. Additional shipping or handling charges may apply on warranty items. CPP shall not be responsible for supply of paper to any point of sale machines ( POS ) that are re-programmed by CPP, its agents, employees, representatives, or independent contractors and will have no warranty obligation for any machines not supplied by CPP for lease or sale. Merchant understands that CPP shall have no liability for any negligent design or manufacture of any non-leased POS terminal, printer or other equipment used by Merchant for the acceptance of credit card transactions. CPP shall not be liable for any incidental or consequential or any economic loss by the merchant whatsoever. Merchant acknowledges additional software, equipment charges, and/or any on-site technical support that may be necessary based on the equipment leased and/or program needs shall be the responsibility of the Merchant and authorizes CPP to debit Merchant s account, via ACH, for any such charges. In addition, Merchant acknowledges a minimum trip charge of Seventy-five (75) dollars will be charged for post setup onsite technical assistance. If Merchant requires re-programming of existing equipment, merchant will be entitled to a loaner terminal for seven business days from ship date of terminal to merchant. Merchant must return loaned equipment promptly after grace period, or will be charged based on equipment model and type but not to be less than $795. Merchant acknowledges that it may incur additional cancellation fees from ancillary service providers under contract that Merchant has with such service providers. Merchant acknowledges it is their full responsibility and leaves (CPP) free of any of these responsibilities. Merchant also acknowledges that any fees paid to CPP at the time of sale are nonrefundable in the event Merchant discontinues Agreement for any reason. Merchant acknowledges that it has fully read and understands each of the terms and conditions in the Agreement, this Addendum, and any other ancillary service provider s agreements and understands that it has receive a copy of such agreements, The Agreement and this Addendum contain the entire agreement of the parties and there are no representations, warranties, covenants, or undertakings of, by or between the parties other than those expressly set forth in the Agreement and/or Addendum. Merchant acknowledges that any oral representations made by the sales agent or representative not contained within the Agreement or Addendum are not binding. Any changes to the Agreement and/or Addendum are invalid unless in writing and signed by CPP and the Merchant. In no event will CPP or its agents, officers, directors or employees be liable for incidental, special or consequential damages. Merchant hereby acknowledges that it has had sufficient and adequate time to review the terms herein, and is voluntarily entering into the Agreement and Addendum. Merchant hereby acknowledges that the person signing this Addendum has the full authority by the Merchant and that such person has had sufficient and adequate time to review the terms herein. Merchant shall indemnify and hold CPP, its agents, employees, representatives, officers, directors, or independent contractors, harmless from any and all liability, loss and damage, including reasonable attorney s fees and costs which may arise as a result, whether direct or indirect, of any act or failure to act or the breach of any warranty by Merchant pursuant to the terms of the Agreement and/or Addendum. I understand that this payment plan may be cancelled by the Service Provider or Merchant due to NSF (Non-sufficient Funds). I will be liable to pay an NSF fee of $25.00 (or the amount allowable by law), which may be automatically debited for each NSF. Wireless terminals are subject to a one time Wireless Activation Fee of $39.99 which shall be collected electronically (ACH). In the event that this agreement is terminated early, Merchant will be responsible for the payment of a $ Early Termination Fee in accordance with Part III, Section A.3 of the Merchant Program Guide. Additionally, the Merchant will be responsible for the Monthly Minimums for the remaining terms of the agreement along with any other monthly charges agreed upon said contract agreement. If Merchant received loaner equipment from CPP, Merchant must return loaned equipment promptly, within 5 days of closure, or will be charged based on equipment model and type but not to be less than $795. If Merchant receives monies, from CPP, for reimbursement to close prior processing accounts and said merchant terminates this agreement early; the Merchant will be obligated to reimburse CPP in full at time of termination. CPP reserves the right to collect the reimbursement electronically (ACH). Bank Name: Bank Ph No.: Routing #: Account #: Merchant's Signature Title Date I understand that there is a one time $50 application fee from Cost Plus Processing LLC.; please initial here: Copyright 2011 [5/27/2014]