Tsys Mpa With Logo 1
Tsys Mpa With Logo 1
0419(WFB)
Legal Phone Number Legal Fax Number DBA Phone Number DBA Fax Number
( _____ ) _____ - _______ ( _____ ) _____ - _______ ( _____ ) _____ - _______ ( _____ ) _____ - _______
Email Address for Notices: ______________________________________________________________________________________________________________________
(See “Notices” in the Merchant Card Processing Agreement included with this application for additional information relating to email address usage.)
Customer Service Phone Number ( _____ ) _____ - _______ Length Owned:
Website Address:__________________________________________________ ______ Years ______ Months
Preferred Address for:
Statements? Legal Address or DBA Address
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How do you advertise? (check all that apply) Yellow pages Telemarketing Catalog Word of mouth Publications Mass/Direct mail Internet
Other, please explain:
Please supply copies of advertising, including catalogs and brochures.
Where applicable, provide video (TV), audio tape (Radio or IVR), and Web-page screen prints. List the URL (www. X .com, .net, .org, etc.) on each page.
Card Types Requested?* Select all that apply. All Credit Cards All Credit and PIN Based Debit Cards PIN Based Debit Cards Only **
*Merchant has the right not to accept all card types. **Point Of Sale programming cannot prohibit the acceptance of credit cards; therefore, it is the merchant’s
TM
responsibility to enforce this. Processor, and not Merchant Bank, will settle American Express, PayPal In-Store, Discover, and JCB transactions.
Credit Card Processing Methods Do you use a third party fulfillment Average Credit/Debit Total Credit/Debit
house? Yes No Transaction (Ticket) Monthly Sales:
Card Swiped Transactions % Amount:
If yes, provide name and address. $ _____________
Manually Keyed (Card Present with Imprints) % $ __________
Manually Keyed (Card Not Present and/or Mail Order/Telephone Order) % _____________________
eCommerce (Card Not Present) %
_____________________
_____________________
Total (must equal 100%) 100 % _____________________
Business to Business (must be 0 - 100%) %
Does annual American Express volume exceed $1,000,000? Yes No Would Merchant like to receive American Express marketing materials Yes No*
*By checking ‘No’ merchant opts out of receiving future commercial marketing communications from American Express. Note that you may continue to receive marketing
communications while American Express updates its records to reflect your choice. Opting out of commercial marketing communications will not preclude you from receiving
important transactional or relationship messages from American Express.
Seasonal Business? Yes No If Yes, indicate by “X” the months that are ACTIVE: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
List the names of each of your independent contractors or agents that will have access to, store, process, or transmit cardholder data, including online shopping carts, payment
gateways, hosting companies, and order-taking services. (Provide separate pages if needed).
6. BANKING INFORMATION
Name and Phone Number Routing Number Bank Account Number Use this account for*:
Type of Accounts
of Financial Institution (Shown on the bottom of check) (Shown on the bottom of check) (select all that apply)
checking daily settlement TXP ACH settlement
1.** savings monthly billing TXP ACH fees
general ledger chargebacks
checking daily settlement TXP ACH settlement
2.** savings monthly billing TXP ACH fees
general ledger chargebacks
*If nothing indicated, Financial Institution #1 will be used for all ACH activity. **AUTHORIZATION FOR AUTOMATIC FUNDS TRANSFER (ACH): The Merchant Bank (defined on page 1) is authorized to initiate or
transmit automatic debit and/or credit entries and/or check entries to the account identified above and in the provided voided check (if applicable) relating to the above account (**) for all services contemplated under
this Agreement. Said authority is granted to Merchant Bank’s Processor and their agents. This authority is to remain in effect until Merchant Bank or its agents receive written notice from Merchant revoking it. You
understand that you will be considered the Receiver of all ACH entries submitted hereunder, and agree to comply with all rules and operating guidelines of the NACHA Rules and other relevant clearing house
associations which are applicable to Receivers, as the same may be applicable to transactions processed hereunder.
7. TRADE REFERENCES
Trade Name Account Number Phone Number Product Sold (if applicable)
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8. FEE SCHEDULE
PRICING (Select One): QMNRC Differential Pass Through TransFreedom PROCESSING TYPE: Retail MOTO TTC
Fee Category: Voice/ARU Auth Fee Chargeback Fee
Visa/MC/AXP/DISC/PP/JCB/
Discount Rate Authorization Fee Per Item Fee 1.95 25.00
Diners Cards (if applicable) $ ___________ $ ___________
Qualified or Plus Rate: All Card Types Batch Close Fee Retrieval Fee
(Retail, MOTO, Internet) _____________ % $ ______________ .25 15.00
$ ___________ $ ___________ $ ___________
Mid-Qualified Surcharge: Monthly Minimum Discount Application Setup Fee
(Retail Only) _____________ % $ ______________ 25.00
$_______________ $_______________
Non-Qualified or Monthly Service Fee Reprogramming Fee
Differential Surcharge: 0.10
_____________ %
$ ______________ 15.95
(Retail, MOTO, Internet) $_______________ $_______________
____________ % TransFreedom Monthly Fee Terminal Support Fee
Rewards Surcharge:
(Retail Only) with Qualified
Rewards at Pass Thru $ _______________ $ _______________
Standard Card
Check Card Rebate: Rebates 69.00
Annual Fee: $____________
(Signature Based) Card Rebates at Admin Fee: $___________
Full Difference $ _____________ 12/01/2019
Start Date: ______________
-____________
ACH Return Fee Merchant Savings Club
Fees for Access to Card Brand 0.13 0.05 $ ___________ Monthly Fee $ ___________
_____________ % $ _____________
Services (see description below) Payment Gateway Monthly Payment Gateway Setup
$____________ $____________
The following association-related fees, as adjusted or allocated by TSYS, may be added to “Fees for Access to Card Brand Services” billing bundle or be itemized on merchant statements - Cross border
international transaction assessments/program support, MC network access/brand usage (NABU), MC Digital Enablement, MC license fee, MC Safety Net, MC Account Status Inquiry Service (ASIS) fee, Visa
US acquirer processing fee (APF), Visa Zero Floor Limit, Visa misuse of the authorization system, Visa FANF, Visa integrity, Credit Voucher fee for Visa, MC processing integrity, Discover data usage and
American Express Access and System Processing fees. Further Visa / MC / AXP / DISC / PP fees, including association Base II and kilobyte fees, Visa / MC / AXP / DISC / PP assessments, and $15 Annual
Location Fee for MC may also apply. Batch Close Fee: All batch closing and batch inquiries are considered “transactions” and will be billed at the same rate as Visa / MC / AXP / DISC/PP Trans Fees unless
specified. Monthly Minimum Discount: Applies to Discount Rate & captured transaction fees. Qualified T&E Surcharge of .60% will apply to T&E merchant transactions. TransFreedom: In addition to your
TransFreedom Monthly fee, Automatic Volume Purchase billing may apply to volume processed in excess of the current pricing tier at a rate of $20.00 per every $500.00 in additional processed volume. Invalid
Data Fee: a $25 per month fee will be applied to your account if you have provided us with an invalid tax identification number or incorrect name for your company.
Note: Processor and its contractors provide the additional products and services set forth in sections 9, 10 and 11, in addition to Purchasing Cards, Corporate Cards and Fleet Cards and the Invalid Data Fee
above. Merchant Bank does not provide such services and has no responsibility or liability for them.
9. ADDITIONAL SERVICES AND TERMS
Petro/Fleet (Petro Addendum required)
ACH Processing (ACH Addendum required) Check Services (CrossCheck Application required)
Voyager Wright Express (WEX)
TransLink Insights
Merchant is provided a 60 day free trial period. Merchant will be billed $29.99 per location per month if not cancelled during the free trial period. These products and services are
provided by Processor and not Merchant Bank. Merchant Bank has no obligation or liability for this product or service.
By checking this box, Merchant declines to participate in the TransLink Insights product.
PIN Debit/EBT
PIN Based Debit Per Item Fee* $ _______ PIN Based Debit Monthly Fee $ ________ PIN Based Debit Application Fee $ _________ EBT Per Item Fee $ _________
*Debit Discount Rate: NOTE - PIN Based Debit authorization and interchange fees may apply.
TransIT/Transaction Express/Transaction Central/ Sierra Semi Integrated Processing Services
TransIT Product: WebPASS MultiPASS THP TSEP Vital Select Vital Plus Vital Mobile
Setup Fee $___________ (One time per POS) Monthly Fee $_________ (per POS) Data Protection $_________ (per Item)
TC TC Plus TC Setup Fee $___________ (One time per POS) TC Monthly Gateway Fee $_________ (per POS) TXP Direct Swipe Monthly Fee $ ___________
TXP ACH TXP Package Setup Fee $___________ (One time per POS) TXP Package Monthly Fee $__________ (per POS) Integration Fee $_________
QB Payment Terminal Setup Fee $___________________ (per TXP ID) QB Payment Terminal Monthly Fee $___________________ (per TXP ID)
ACH Discount Rate __________% ACH Trans Fee $______________ ACH Return Fee $_______________ Fraud Check Fee $_______
Wireless and Other Services
PCI Quarterly Program Fee* $ _______
Wireless Setup Fee Wireless Monthly Gateway Fee Other Fee: $__________ (PCIQ, PCIM, PCIB)
*Fee will be reduced to $_____ for ongoing
$ _________ (One Time/Per Terminal) $ ________ (Per Terminal) Description:_______________________ support once compliance is validated.
Monthly PCI Monthly Non Validation Fee
Petro/Fleet (per Terminal) SmartLink (per Modem) Semiannually Section 11.2(d) Fee (as stated in the $______ (PCIM)
Setup Fee: $ ___________ Setup Fee: $ ________ Merchant Card Processing Agreement)
Breach Coverage Fee
does not apply if checked PCI Monthly Program Fee** $ _______
Monthly Fee: $__________ Monthly Fee: $_______ $ ______________ (PCIC)
**Fee will be increased to $_____ for
Breach Enrollment Fee $_________ (PCIC) If at any time MERCHANT is not validated for PCI compliance and has opted out of ongoing support if compliance is not
Breach Coverage, MERCHANT will be automatically enrolled in the Breach Coverage program at the rate indicated above, until validated 75 days after signing.
such time that MERCHANT restores validation and opts out, at which point MERCHANT will again be opted out.
10. EQUIPMENT OPTIONS
Industry: Retail Retail w/ Tips Restaurant MOTO QPS Retail QPS Restaurant Lodging Petro/Fleet Cash Advance
Equipment shipped to: DBA Legal Agent Other* N/A Merchant trained by: Agent TSYS Other*
Welcome Kit sent by: Agent TSYS Welcome Kit shipped to: DBA Legal Agent Other* N/A
*If Other was selected above, provide shipping details below.
*Name: *Address:
*City: *State: *Zip:
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Item
Model Version/SIM# Qty Code** Price** Bill To** FEATURES
Description
Terminal PIN Based Debit Yes No Dial Prefix
Software Name Store & Forward Yes No Memory Size 512K 1Meg
Merchant Email Address (Required): Tip at Time of Sale Yes No Tip Calculator Yes No
**Shipping, handling, and tax will be billed in addition to the equipment price listed above. If merchant owned WAY terminal, SIM # & Serial # required. Bill To Options: Merchant, Agent, TSYS, N/A
Codes: FU = Free use, MO = Merchant owned, PN = Purchase new, PO = Purchase via other source, PRF = Purchased refurbished, FLS = First Data Leasing, EE = Encryption exchange, RTL = TSYS rental
program or STR = Short term rental. Any free use equipment provided by TSYS is the property of TSYS and is being provided for free use and Merchant agrees that it has read and agrees to the terms and
conditions regarding such free use equipment as set forth in the Merchant Card Processing Agreement located at www.TSYS.com/documents and included with this application.
11. TRANSIT/ TXP/TC/SIERRA SEMI INTEGRATED HARDWARE AND CONFIGURATION ***Required Data
Product: TransIT Sierra Semi Integrated Transaction Express Transaction Central TC Plus (CC & ACH – ACH Addendum required)
TransIT Product: WebPASS MultiPASS THP TSEP Vital Select Vital Plus Vital Mobile
TXP Input Types: Virtual Web Services Batch Post Hosted Industry: Retail MOTO eCommerce
***Integrated Product Name: ***Integrated Website Address:
***Welcome Email Address:
TRANSIT FEATURES SIERRA SEMI INT FEATURES TXP FEATURES*
Auto Batch Close Time Forced Re-Credit Y Tokenization Default Custom Batch Close Method M/A
Location Type CNP Batch Y Custom Tokenization MID: Direct Swipe Y
Headquarter MID Enhanced Data (Level II & III) Y Partial Authorization Y
Tokenization: Default Custom PIN Debit Y Batch Response File Y
Custom Tokenization MID: Mandatory Security Code Y File Split Y
EnsureBill: InFlight Standard Apple Pay Y Private Label Y
Partial Authorization Y Samsung Pay Y PIN Debit Y
Forced Authorization Y Device Type: Android iPhone TC FEATURES*
Item Description Config/Color QTY Code Price Bill To Batch Close Method A M Corp/Purch Cards Y
Recurring Method A M Duplicate Card Accept Y
Special Instructions:
**Shipping, handling, and tax will be billed in addition to the equipment price listed above. Bill To Options: Merchant, Agent, TSYS, N/A
Codes: FU = Free use, MO = Merchant owned, PN = Purchase new, PO = Purchase via other source, PRF = Purchased refurbished, PI=Purchase Installments, FLS = First Data Leasing, EE = Encryption
exchange, RTL = TSYS rental program or STR = Short term rental. Any free use equipment provided by TSYS is, as between Merchant and TSYS, the property of TSYS and is being provided for free use and
Merchant agrees that it has read and agrees to the terms and conditions regarding such free use equipment as set forth in the Merchant Card Processing Agreement located at www.TSYS.com/documents and
included with this application.
PLEASE CAREFULLY REVIEW THE MERCHANT CARD PROCESSING OPERATING GUIDE (the “OPERATING GUIDE”) AND THE TERMS AND CONDITIONS OF VERSION
v18.0119 OF THE MERCHANT CARD PROCESSING AGREEMENT (the “MPA”) AVAILABLE AT WWW.TSYS.COM/DOCUMENTS, EACH OF WHICH IS HEREBY
INCORPORATED BY REFERENCE. IF APPLICABLE, PLEASE ALSO CAREFULLY REVIEW THE TERMS AND CONDITIONS OF VERSION V6.0419 OF THE CARD NOT
PRESENT ADDENDUM TO THE MERCHANT CARD PROCESSING AGREEMENT AVAILABLE AT WWW.TSYS.COM/DOCUMENTS, WHICH IS HEREBY INCORPORATED BY
REFERENCE.
Agreement Signature: As the person signing below on behalf of the business designated on the above application as the Merchant, I certify that I am an owner, partner or officer of the
Merchant and have been duly authorized to sign this application and to bind the Merchant to the MPA and the Operating Guide. Merchant and each Guarantor signing below hereby
acknowledge that they have each read this application and the MPA and agree to be bound by the terms and conditions contained in these documents. Merchant (and Guarantor when
applicable) by signing below agrees to comply with the Operating Guide. Merchant certifies that all information provided in this application is true, correct and complete. Merchant (and
Guarantor when applicable) authorizes the Merchant Bank and Processor or their respective agents to make whatever inquiries the Merchant Bank or Processor deems appropriate to
investigate and verify any of the credit, financial and other information given by Merchant for the purpose of this application, including credit references and to obtain credit reports on
each person signing below. Credit or other information on Merchant, owners, officers and any guarantors of the Merchant may be requested for purposes of this application and during
the merchant processing relationship pursuant to the MPA.
By affixing their signature(s) below, any/all Personal Guarantor(s) do hereby agree to assume personal responsibility to Merchant Bank and/or Processor in the event of default of any
obligation by the Merchant under the terms of the MPA. The responsibility of the individual guarantors shall accrue for all obligations due to Merchant Bank and/or Processor under the
MPA and all applicable laws, rules, and/regulations.
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If ‘RTL’ or ‘STR’ is indicated in Section 10, then by signing below, and upon receiving delivery of the rental equipment, Merchant represents that Merchant has read and agrees to be
bound by the terms of either the POS Portal Rental Agreement or the Equipment Terms set forth in Section 24 of the Merchant Card Processing Agreement (as applicable). If renting
equipment from POS Portal, Inc. (“POS Portal”) Merchant authorizes POS Portal to verify the application information and receive and exchange information about Merchant, including
requesting reports from consumer reporting agencies. If ‘FLS’ is indicated, then by signing below and upon receipt of the First Data Global Leasing (FDGL) equipment, Merchant
represents that Merchant has read and agrees to be bound by the terms of the Equipment Lease Agreement.
Processor will settle your American Express®, PayPal In-Store Checkout and Discover® transactions and (a) Merchant will receive one consolidated statement from Processor that will
reflect Merchant’s Visa, MasterCard, American Express, PayPal In-Store Checkout and Discover transactions; (b) Merchant’s American Express, PayPal In-Store Checkout and Discover
settlement funds will be paid at the same time and in the same manner as Merchant’s Visa and MasterCard settlement; and (c) Merchant will not have a direct relationship with American
Express, PayPal or Discover and the terms set forth in the MPA for American Express, PayPal In-Store and Discover transactions will apply. By signing below, Merchant agrees to be
bound by the PayPal Operating Regulations for In-Store Checkout and the American Express merchant requirements contained in the Operating Guide. Merchant consents to the
disclosure of transaction data, merchant data and other information about the Merchant to American Express and to the use by American Express of such information to perform its
responsibilities in connection with the provision of its services, to promote the American Express Network, perform analytics and create reports, and for any other lawful business
purposes including marketing purposes. Merchant agrees American Express may use any information in this application to screen and/or monitor Merchant in connection with American
Express card marketing and administrative purposes.
If the TransFreedom Program is selected above, then by signing Merchant acknowledges, accepts and agrees that pricing is based upon processed volume and average ticket size and
that this pricing may be subject to Automatic Volume Purchase billing, in addition to the TransFreedom monthly fee, if Merchant’s actual processing volume exceeds its current pricing
tier. Merchant accepts and agrees that it is obligated for all monthly pricing based on its processed volume and average ticket size, including any applicable Automatic Volume Purchase
billing.
If Check Services is selected above, then CrossCheck acceptance shall be added to this application and by signing below, Merchant agrees to be bound by and perform in accordance
with all the terms and conditions and provisions of the Check Services Agreement and as set forth by CrossCheck. Merchant acknowledges that the Terms and Conditions for Check
Service will be sent to Merchant upon approval by CrossCheck.
By electing to process Credit Card and/or Debit Card transactions and by signing this application, Merchant grants consent and authorization to Merchant Bank or its agents or designated
representatives to initiate automatic debit and credit entries and adjustments to the Settlement Account and any Reserve Account through the ACH Settlement Process for the amounts
due under and in accordance with the terms and conditions of the this application and the MPA.
By electing to process ACH transactions and by signing this application, Merchant grants consent and authorization to Processor or its agents or designated representatives to initiate
automatic debit and credit entries and adjustments to the Settlement Account and any Reserve Account through the ACH Settlement Process for the amounts due under the Automated
Clearing House (ACH) Addendum and ACH Terms and Conditions available at WWW.TSYS.COM/DOCUMENTS, which are incorporated by this reference. By signing below Merchant
acknowledges that it has read and agrees to be bound by the ACH Addendum and the ACH Terms and Conditions (v6.1018TC for TC Plus or v4.1018TXP for TransIT/TXP ACH
depending on processing services selected in Section 9).
Merchant certifies that Merchant does not and will not provide, offer or facilitate gambling services, including offering or facilitating internet gambling services, or establishing quasi-cash,
credits or monetary value of any type that may be used to conduct gambling.
Any unilateral alteration, strikeover or modification to the preprinted text or line entries of the application or MPA shall be of no effect. Merchant acknowledges that the parties may
produce and rely upon a copy or electronically stored image of the merchant application and MPA for all legal purposes.
12. MERCHANT(S) SIGNATURE(S) GUARANTOR(S) SIGNATURE(S)
1) 1)
Merchant Signature (Owner or Officer) Date Guarantor Signature Date
2) 2)
Merchant Signature (Owner or Officer) Date Guarantor Signature Date
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Merchant Resources
You may download “Visa Regulations” from Visa’s website at:
https://usa.visa.com/support/small-business/regulations-fees.html#3
You may download “Mastercard Rules” from Mastercard’s website at:
http://www.mastercard.com/us/merchant/support/rules.html
The responsibilities above do not replace the terms of the Merchant Card Processing Agreement and are provided to
ensure the Merchant understands some important obligations of each party and that the Bank is the ultimate authority
should the Merchant experience any problems.
*Business Address:
*Title:
*Date:
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