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Merchant Processing Application Form

The document is a merchant processing application for a fitness equipment business. It collects business and owner information like the business name, address, tax ID, and percentage of different types of transactions processed. It also lists the pricing for different types of card processing like credit card and debit card interchange fees.

Uploaded by

Nicole Bilello
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© © All Rights Reserved
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0% found this document useful (0 votes)
107 views4 pages

Merchant Processing Application Form

The document is a merchant processing application for a fitness equipment business. It collects business and owner information like the business name, address, tax ID, and percentage of different types of transactions processed. It also lists the pricing for different types of card processing like credit card and debit card interchange fees.

Uploaded by

Nicole Bilello
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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MERCHANT PROCESSING APPLICATION Paymentcloud, is a registered DBA of EPX, a registered ISO of

BMO Harris Bank N.A., Chicago, IL, Fresno First Bank, Fresno, CA,
and Citizens Bank N.A., Providence, RI

☑ New Account ☐ Additional Location ☐ Change of Ownership


Sales Rep: 53413 Sales Rep Phone: (800) 226-2273 Sales Rep Email: admin@paymentcloudinc.com,bgreen@paymentcloudinc.com

Sales Rep Fax: (248) 269-2222 Merchant ID (MID): MCC Code: 7997

BUSINESS INFORMATION:

DBA (Doing Business As) Name: Business/Corporate Name: (as shown on your Income Tax Return)
Kowens Fitness World Kathy Owens
Location Address: City: State: Zip:
585 Stage Coach Rd Woodstock VA 22664
Statement Mailing Address: City: State: Zip:
407 W 1st St Joplin MO 64801
Business Phone Number: Business Fax Number:
(323) 916-4956
Email: Website:
kowensg50@gmail.com http://kowensfitnessworld.com
Bank Name: Name on Bank Account: Checking Account #: Bank Routing #:
**********5084 *****0195
Federal Tax ID: TIN Type: Contact Name:

* * * * * 9 7 4 2 ☑ EIN ☐ SSN Kathy Owens

Type of Merchant: Statement Option Type:


☑ Sole Proprietor☐ Partnership ☐ LLC☐ Corporation☐ Non-Profit Other _______________ ☑ Electronic☐ Paper
Business Processing Category:
☐ Retail ☐ Restaurant ☑ MOTO ☐ Internet ☐ Other ______________________________________
Merchandise/Services Sold: Years in Business:
fitness equipment
Currently accept Visa/MasterCard/Discover/AXP? Seasonal Merchant: If yes, indicate active J F M A M J J A S O N D
☐ Yes ☐ No ☐ Yes ☑ No months:

Percent of Business: (must equal 100%)


Card Swipe: 0 % Manually Keyed: 0 % Phone/Mail Order: 100 % Internet: 0 % Total: 100 %

Avg Ticket: High Ticket: Avg Monthly Volume: High Monthly Volume:
7000 5000 15000
Transaction Descriptor to Appear on Cardholder's Statement: Customer Service Phone Number to
Appear on Cardholder's Statement:

OWNERS AND OFFICERS: List all owning 25% or more business equity. Use addendum to list additional

Name: Title: Applicant's SS#: Date of Birth: Equity Ownership:


Kathy Owens owner *******9742 1961-03-24 100 %
Residence Address: City, State, Zip: Phone Number:
585 Stage Coach Rd Woodstock, VA, 22664 (323) 916-4956
Name: Title: Applicant's SS#: Date of Birth: Equity Ownership:

Residence Address: City, State, Zip: Phone Number:

PRIMARY CONTROL CONTACT: List person responsible for control/management of account (CEO, COO, Manager, etc.).

Name: Residence Address: City, State, Zip: Date of Birth: SS#:


Kathy Owens 585 Stage Coach Rd Woodstock, VA, 22664 1961-03-24 *******9742
SERVICES REQUESTED:

American Express Volume > $1,000,000 Discover Retained SE#:


☐Yes*☑No*Account#:
EBT: ☐Cash Benefits ☐Food Stamp (SNAP)* PIN DEBIT (ex. STAR, NYCE, INTERLINK, PULSE, MAESTRO)

Accepting all MasterCard, Visa, Discover Network, and American Express transactions (presumed unless any selections below are checked)
MasterCard Visa *Discover Network *American Express
☐Credit Transactions Only ☐Credit Transactions Only ☐Credit Transactions Only ☐Credit and Prepaid Card Transactions
☐Non-PIN Debit Trans ☐Only Non-PIN Debit Trans ☐Only Non-PIN Debit Trans
*Discover full-acquired unless ineligible for program (e.g. Discover retained merchants provide your Discover SE# above)
*AXP full-acquired unless ineligible for program (e.g. merchants over $1MM annual AXP volume, prohibited or do-not-sign merchants) provide your AXP-direct account SE# above.

All questions regarding this All questions regarding merchant

application should be directed to: processing should be directed to:


Paymentcloud Paymentcloud
16501 Ventura Boulevard Suite 300 250 Stephenson Hwy.
Encino, CA 91436 Troy, MI 48083
888-919-9333 1-866-485-8999 Initials 198.96.95.207
EPX0718 1 OF 3
PRICING SCHEDULE

Moto Interchange Plus


Interchange, dues, & assessments +100 bps
Transaction Fee: $0.10

OTHER FEES (if applicable) M=Monthly MPD=Monthly Per Device PA=Payanywhere MC=MasterCard DIS=Discover AXP=American Express IC=Interchange

T&E Draft Capture Tran: $0.00 IC Passthrough Credit: $0.10 IC Passthrough Check: $0.22 Internet Gateway(M): $0.00
Debit Gateway(M): $0.00 EBT Transaction: $0.00 Internet Transaction: $0.00 Minimum Discount(M): $25.00
Basic Service(M): $10.00 Statement Mailing: $0.00 Chargeback: $25.00 Retrieval: $15.00
Voice Authorization: $0.00 Touch Tone Transactions: $0.00 Address Verification: $0.05 Batch Header: $0.30
Debit Transaction: $0.35 Wireless Transaction: $0.00 Wireless Network(M): $0.00 Wireless Activation: $0.00
Settled Transaction Fee: $0.00 A920 Ethernet Dock Rental: $0.00 PA Cellular Data(M): $9.95 PA Cellular Data Tran: $0.10
PCI Compliance(M): $12.00

MC Network Access $0.0208 Visa Network Access $0.0218 DIS Network Access $0.0195 AXP Network Access 0.165%
PayPal Network Access $0.0195

I acknowledge that I will receive 60 days of free, premium plus access to the Payments Hub, after which I will be charged a monthly fee of $29.95 for continued premium access,
which includes an equipment warranty program and free supply ordering. I understand that I may opt out of this premium access at any time while still enjoying the free features of
the Payments Hub by emailing support@paymentshub.com or calling 877-464-4218.

CERTIFICATION & AGREEMENT


Merchant acknowledges that you have accessed our Merchant Processing Agreement ("Agreement") at www.myresourceportal.com/agreement. By signing below, Merchant agrees to
all terms and conditions contained therein. From time to time, the Agreement may be updated. When this occurs, Agent will notify Merchant electronically (or by delivery method
selected by Merchant at time of disclosure) when such updates have been made. Merchant acknowledges that continued use of Agent Merchant services after the update signifies
Merchant Acceptance of updated Agreement. The undersigned is duly authorized to sign on behalf of the Merchant and to bind the Merchant to the terms and conditions set forth in this
Merchant Application ("Application") and previously referenced Agreement, and certifies that all information provided in association with this Application is true, correct and complete.
By signing below on behalf of Merchant, you authorize Member/Bank and/or Agent to collect and use your Social Security number, including for purposes of obtaining consumer credit
reports on you. You expressly acknowledge and agree that your Social Security number and your consumer credit report(s) may be required or used in conjunction with the
maintenance, updating, renewal or extension of the services provided hereunder, or in conjunction with reviewing, taking collection action on, or any other legitimate purpose
associated with the Merchant account. The undersigned consents to Member/Bank and/or Agent's collection, processing and use of the information contained in this application
including the transfer of such information to service providers or affiliates for any lawful purpose including, without limitation, to (i) verify individual identities, and (ii) transfer such
information, including personal information, to one or more vendors providing a service that assists Member/Bank and/or Agent with respect to identity confirmation. A Merchant's
submission of a transaction to Agent shall be deemed to signify Merchant's acceptance of the Agreement, including the terms and conditions herein.
Merchant: By 198.96.95.207 Merchant: By

(Merchant Principal or Corporate Officer Signature) (Merchant Principal or Corporate Officer Signature)

Kathy Owens

(Print Name) (Print Name)

Date: 2023-07-12 Date:

PERSONAL GUARANTY
In consideration of Agents and Bank's acceptance of this Agreement, the undersigned Guarantor (jointly and severally if more than one) unconditionally guarantees the performance of
all obligations of Merchant to Agent and Bank under the Agreement, and payment of all sums due hereunder, and in the event of default, hereby waives notice of default and agrees to
indemnify Agent and Bank for all funds due from Merchant pursuant to the terms of the Agreement. Guarantor waives any and all rights of subrogation, reimbursement or indemnity
derived from Merchant, and further waived any and all rights or defenses arising by reason of any modification or change in the terms of the Agreement whatsoever, including, without
limitation, the renewal, extension, acceleration, or other change in the time any payment or other performance hereunder is due, and/or any change in any interest or discount rate or
fee hereunder. Guarantor confirms that Guarantor, collectively or individually, is a party to the Agreement and, unconditionally and specifically authorizes Agent and Bank, or its
authorized agent, to debit any overdue fees, costs, chargebacks, fines, fees, penalties, expenses or obligations under the Agreement and/or any contractual relationship with Agent
and Bank from any personal checking or other account owned or controlled by Guarantor, and further to report any default hereunder on Guarantor's personal Credit Bureau Report.
Guarantor agrees to pay all costs and expenses of whatever nature, including attorney's fees and other legal expenses, incurred by or on behalf of Bank in connection with the
enforcement of this Guaranty.

Merchant: By 198.96.95.207 Merchant: By


(Guarantor Signature) (Guarantor Signature)

Kathy Owens
(Print Name) (Print Name)

Date: 2023-07-12 Date:


EPX0718 2 OF 3
BANK AND MERCHANT AGREEMENT DISCLOSURES
Merchant Bank Information
BMO Harris Bank FFB Bank
8500 Governor's Hill Drive 7690 N Palm Ave # 101
Cincinnati, OH 45249 Fresno, CA 93711
847-240-6600 559-439-0200

Upon approval the merchant bank will be selected and stated in your welcome letter. The selection is referred to herein as the "Bank".

Important Bank Responsibilities

1. Bank is the only entity approved to extend acceptance of VISA products directly to a Merchant.
2. Bank must be a principal to the Merchant Agreement.
3. Bank is responsible for educating Merchants on pertinent VISA Operating Regulations or such pertinent rules and regulation of MasterCard International
with which merchants must comply. Merchant acknowledges it has read and understood, or seek clarification from Agent or the Bank, all such rules and
regulations before submitting a transacation for processing by Agent and Bank.
4. Bank is responsible for and must provide settlement funds to the Merchant.
5. Bank is responsible for all funds held in reserve that are derived from settlement.

Merchant Information

Merchant Name: Kowens Fitness World


Merchant Address: 585 Stage Coach Rd Woodstock, VA, 22664
Merchant Phone: (323) 916-4956

Important Merchant Responsibilities

1. Ensure compliance with cardholder data security and storage requirements.


2. Maintain fraud and chargebacks below thresholds.
3. Review and understand the terms of the Merchant Agreement.
4. Comply with VISA, MasterCard, And American Express and Discover Operating Regulations.
5. You may download Visa Regulations from Visa's website at: https://usa.visa.com/support/small-business/regulations-fees.html
6. You may download MasterCard Regulations from MasterCard's website at: http://www.mastercard.com/us/merchant/support/rules.html
7. You may download the American Express Merchant Operating Guide from American Express' website at:
http://www.americanexpress.com/merchantopguide
8. You may download additional merchant information from Discover Network's website at: http://www.discovernetwork.com/merchants/index.html

Important Merchant Agreement Disclosures

1. The initial term of your Merchant Agreement may be either: (a) 3 years (month-to-month thereafter), (b) 2 years (month-to-month thereafter), (c) 1 year
(month-to-month thereafter), or (d) month-to-month.
2. You must provide 30 days' notice to terminate your Merchant Agreement prior to the expiration date of a Merchant Agreement with a 3-year, 2-year or 1-
year initial term. If your Merchant Agreement is month-to-month, you may terminate the agreement at any time upon 30 days' notice.
3. You may terminate the Merchant Agreement within 45 days after executing the Merchant Agreement with no further obligations provided that you return
all equipment within 30 days following the date of your termination notice. See Section 1.16(f) of the Merchant Agreement for details.
4. You may initiate termination of the Merchant Agreement by sending your Merchant name, address and MID via overnight carrier or certified mail to
Agent, 250 Stephenson Hwy., Troy, MI 48083 Attn: Customer Care. You may call Customer Care at (866) 485-8999 (Ext. 1300) if assistance is needed
or you may contact your sales agent.
5. If your Merchant Agreement has an initial term of 3-years, 2-years or 1-year and you elect to terminate your Merchant Agreement prior to the expiration of
such term, you may be responsible to pay an early termination fee of not less than $295.
6. For applicable fees payable by Merchant, you should review the (a) the Merchant Application, (b) Section 1.15 of the Merchant Agreement, and (c) any
additional fee schedule.
7. You understand that all fees may be modified or new fees introduced upon written notice to you. IMPORTANT - Within 30 days after a fee increase or the
introduction of a new fee, you may terminate the Merchant Agreement without obligation to pay any applicable early termination fee other than fee
increases or new fees caused by a Card Network or other 3rd party passed through to Merchant.
8. You specifically authorize Servicers to debit your approved bank account(s) for fees, Chargebacks, returns, fines and any other penalties or amounts
owed under the Merchant Agreement.
9. You will be responsible for any monthly minimum fees, if any, set forth on the Merchant Application, as such fees may be adjusted from time to time.

The responsibilities listed above do not supersede terms of the Merchant Agreement and are provided to ensure the Merchant understands some important
obligations of each party and that the VISA Member– Bank –is the ultimate authority should the Merchant have any problems.

The purpose of the Important Merchant Agreement Disclosures is to provide the Merchant with an overview of key terms and conditions of the governing
Merchant Agreement. The terms and conditions provided within this disclosure are not an exhaustive representation of all terms, conditions, rights or
obligations under the Agreement. Defined terms used in this disclosure may be found in the Merchant Processing Agreement located at
www.myresourceportal.com/epx_agreement.

Merchant Acknowledgment: 198.96.95.207 (Signature)


Name & Title of Signatory: Kathy Owens , owner
Date: 2023-07-12

EPX0718 3 OF 3
AMENDMENT TO MERCHANT PROCESSING AGREEMENT

This Amendment to Merchant Processing Agreement (the "Amendment") is made and entered into as of
the day of ____ , 2023 (the "Effective Date") by and between Paymentcloud ("PC") a Delaware limited
liability company, the business address of which is 16501 Ventura Boulevard Suite 300, Encino, CA
91436, and [ Kathy Owens ] ("Merchant") a [ Sole Proprietor ], the business address of which is [
585 Stage Coach Rd ].

RECITALS

A. On or about [ 2023-07-12 ], Paymentcloud ("PC"), and Merchant executed and


delivered that certain Merchant Processing Agreement (the "Agreement");

B. PC and Merchant have agreed to amend the Agreement as provided herein.

NOW, THEREFORE, for and in consideration of the foregoing Recitals and the mutual covenants and
agreements set forth herein, the parties agree as follows:

1. The terms of this Amendment will be effective as of the Effective Date.

2. Section 1.16 (Term and Termination) of the Agreement is hereby amended and changed so
that Merchant shall no longer be liable for the payment of any minimum monthly fee commitments
(including the $295 minimum) for the remainder of Agreement's initial term if the Merchant
terminates the Agreement prior to the end of such term.

3. Capitalized terms used but not otherwise defined in this Amendment will have the meanings set
forth in the Agreement. This Amendment, together with all exhibits attached here to, constitutes
the entire agreement between the parties regarding the subject matter hereof and supersedes all
prior and contemporaneous agreements and understandings. In the event of a conflict between
this Amendment and the Agreement as it relates to the subject matter hereof, the terms of this
Amendment shall control. Otherwise, all terms and conditions of the Agreement will remain in full
force and effect and likewise apply to this Amendment.

The parties have executed this Amendment as of the date first above written.

Paymentcloud Merchant
By: By: 198.96.95.207
Name: Name: Kathy Owens
Title: Title: owner
Date: Date: 2023-07-12

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