

X
New Location
Additional Location  MERCHANT APPLICATION
Change of Ownership  Merchant#_______________________________________
1800-609-4213 SIC Code ___________ Sales Rep.# ____________Location # ________of________
BUSINESS INFORMATION
Business/Corporate Name (as shown on your Income Tax Return) Statement Mailing Address (if different from location address)
La Reyna De Oros Market
DBA (Doing Business As) Name City, State, Zip
La Reyna De Oros Market ,,
Location Address Business Phone Number FAX#
102 W Moreland Ave 2157911987
City, State, Zip E-Mail
Hatboro, PA, 19040
Website Address (URL) Statement Option Type
http://www. Electronic  X Paper
Bank Reference (Name) Bank Reference (Phone #) Federal Tax ID (As shown on Income Tax Return) TIN Type:
Wells Fargo EIN (Federal Tax ID)  SSN
Checking Account # Bank Routing #  I certify that I am a foreign entity /
nonresident alien
Contact Name
9178636842 031000503 (if checked, please attach IRS Form W-8.)


X Sole Proprietor  Partnership  Corporation  Non-Profit  Medical/Legal Corporation  LLC Percent of Business (Must Be 100%)
CARD SWIPED KEYED WITH KEYED WITHOUT
 Tax Exempt Organization  International Organization Association/Estate/Trust  Government IMPRINT OF CARD IMPRINT OF CARD
How long
in present
Number of Do you currently accept Visa/MasterCard/Discover? X Yes  No 80.00 % 20.00 % %
business Years locations? (If yes, you should submit 3 most current monthly statements.) Sales Method (Must Be 100%)
State of Incorporation Merchandise/Services Sold Monthly Bank Card Sales Seasonal:  Yes  No STORE FRONT OFF PREMISE MAIL/PHONE ORDER
Food $ 6000 100.00 % 0.00 % 0.00 %
High Volume Months
Gross Yearly Sales Average Ticket Amount Highest Ticket Amount TRADE SHOW OTHER INTERNET SERVICES
$ $ 5.00 $ 70.00 0.00 % 0.00 % 0.00 %
Prior Bankruptcies?  Yes  No If Yes:  Business  Personal Date of Discharge:
American Express * if new, see addendum New Setup  Existing Account#
EBT 
X Cash Benefits  Food Stamp (SNAP)* *Account#
Accept all MasterCard, Visa, and Discover Network Transactions (presumed, unless any selections below are checked)
MasterCard Acceptance Visa Acceptance Discover Network Acceptance
 Accept MC Credit Transactions only  Accept Visa Credit Transactions only  Accept Discover Network Credit Transactions only
 Accept MC Non-PIN Debit Trans. only  Accept Visa Non-PIN Debit Trans. only Accept Discover Network Non-PIN Debit Trans. only
OWNERS OR OFFICERS (Equity Ownership Must be Greater than 50%) Please complete for every person
who ultimately owns or controls the operation or on whose behalf the transactions authorized under this
agreement will be conducted.
Name Title Equity Ownership Applicant’s SS# Date of Birth
1. Alma Katia De Melgar Owner 100% 616160314 06/22/1967
Residence Address City, State, Zip Years at Address Home Phone Driver’s License#
112 W Moreland Ave Hatboro, PA, 19040 9495841305
Name Title Equity Ownership Applicant’s SS# Date of Birth
2.
Residence Address City, State, Zip Years at Address Home Phone Driver’s License#

SMEMBER
OR OFFICERS (Equity Ownership
BANK (ACQUIRER) Must be Greater than 50%)
INFORMATION
IMPORTANT MEMBER BANK (ACQUIRER) RESPONSIBILITIES IMPORTANT MERCHANT RESPONSIBILITIES
1. The Bank is the only entity approved to extend acceptance of Card Organization 1. Ensure compliance with cardholder data security and storage requirements.
products directly to a merchant. 2. Maintain fraud and chargebacks below Card Organization thresholds.
2. The Bank must be a principle (signer) to the Merchant Agreement. 3. Review and understand the terms of the Merchant Agreement.
3. The Bank is responsible for educating Merchants on pertinent Card Organization 4. Comply with Card Ogranization Rules.
Rules with which Merchants must comply; but this information may be provided to 5. Retain a signed copy of this Disclosure Page.
you by the Processor.
4. The Bank is responsible for and must provide settlement funds to the Merchant. The responsibilities above do not replace the terms of the Merchant Agreement and are
5. The Bank is responsible for all funds held in reserve. provided to ensure the Merchant understands some important obligations of each party
and that the Bank is the ultimate authority should the Merchant have any problems.

Merchant Resources The Merchant Legal Name and Federal Tax ID Number shown on this application is
the merchant's correct taxpayer information on file with the IRS. Missing or incorrect
Visa: http://usa.visa.com/merchants/operations/op_regulations.html
information may result in backup withholding from your deposits (currently at least
MasterCard: http://www.mastercard.com/us/merchant/support/rules.html
28% of your gross sales amount) until you provide correct information. Any withheld
Discover Network: http://www.discovernetwork.com/merchants/index.html
funding would be paid directly to the IRS or applicable taxing authority.

All questions regarding merchant For Member Contact: Global Payments

processing should be directed to: Wells Fargo Bank 10705 Red Run Blvd.
PayProTec 1200 Montego Owings Mills, MD 21117
Merchant's Signature ________________________________
250 Stephenson Hwy Walnut Creek, CA 94598
Troy, MI 48083 925-746-4167
1-800-360-2591
Revision 12/13 Page 1 of 11
MERCHANT APPLICATION (cont.)
COMPLETE IF YOUR SALES ARE GENERATED THROUGH MAIL/TELEPHONE/INTERNET
1.Description of product sold:
2.Who owns product?  Merchant  Vendor (Drop Ship Required)
3.List the name(s) of vendors from which the product is purchased.
4.How do you advertise?  Catalog /Direct Mail/Flyers  TV or Radio Internet (list Web Page Address)
5.How does the customer order the product?  Mail  Telephone  Fax  Internet
6.Do your customers sign a service agreement with you?  Yes  No
7.If Yes, what is the timeframe of the service agreement?  Monthly  Quarterly  Annual
8.Name of Fulfillment House (if any) Inspected Yes No Date Inspected
9.Are consumers required to provide a deposit?  Yes  No
10.Delivery Time Frame:  0-7 Days  8-14 Days  15-30 Days  More than 30 Days
11.Shipping Service Used:  Fed Ex  UPS  Airborne  Express Mail  By Merchant
12.What is your return or refund policy?
13.When you receive an authorization, how long before the merchandise is shipped?
14.In what geographic areas will the product be marketed and sold?

BUSINESS TRADE SUPPLIERS (LIST TWO)

Name Address Contact Phone
Name Address Contact Phone

MERCHANT SITE SURVEY REPORT (To Be Completed by Sales Representative)

Merchant Location:  Store Front  Office Building  Warehouse  Residence  Other
The Merchant: Landlord Name Landlord Telephone Number
 Owns  Leases the Premises
I hereby verify that this application has been fully completed by merchant applicant and that I have inspected the business premises of the merchant
at this address and the information stated above is true and correct to the best of my knowledge and belief.
Verified and Inspected by (Print Name) Representative Signature Date

PRICING SCHEDULE Other Fees (if applicable)

Retail MOTO/Internet Dial Pay Transactions: $ 0.50
(if any % is Swiped) (100% Keyed only) T & E Draft Capture Transactions: $ 0.25
Qualified Visa/MC Discount Rate*:1.59% Qualified MOTO Discount Rate*:2.29% Address Verification: $ 0.05
Transaction Fee: $0.25 Transaction Fee: $0.25 Batch Header: $ 0.25
(Must use AVS) Interchange Fee Passthrough
* For details regarding mid and non-qualified Credit: $ 0.10
surcharges, please see page 7 section 32 of *For details regarding non-qualified Check Card: $ 0.22
the terms and conditions. For purposes of surcharges, please see page 7 section 32 of Wireless Transaction Fee: $ 0.10
this agreement the mid-qualified surcharge is the terms and conditions. For purposes of Wireless Network Access (Monthly): $ 20.00
2.69% ($2.69 per $100.00) + $0.10. For this agreement the non-qualified surcharge Wireless Activation Fee: $ 35.00
purposes of this agreement the non-qualified is 2.18% ($2.18 per $100.00) + $0.10. Card Phone Swipe Gateway (Monthly): $ 14.95
surcharge is 3.84% ($3.84 per $100.00) + Association assessments will be passed Phone Swipe Add'l Gateway (Monthly): $ 4.95
$0.10. Card Association assessments will be through. Phone Swipe Transaction Fee: $ 0.05
passed through.
Debit Transaction: $ 0.35
Debit Gateway (Monthly): $ 5.00
MasterCard Network Access Fee: $0.0208 Mastercard Network Access Fee: $0.0208 EBT Transaction Fee: $ 0.20
Visa Network Access Fee: $0.0218 Visa Network Access Fee: $0.0218 Internet Gateway Fee (Monthly): $ 20.00
Discover Network Access Fee: $0.0185 Discover Network Access Fee: $0.0185 Internet Transaction Fee: $ 0.10
PayPal Network Access Fee: $0.0185 PayPal Network Access Fee: $0.0185 PCI Compliance Fee: $ 79.00
Monthly Minimum Discount Fee: $ 25.00
Monthly Basic Service Fee: $ 10.00
Statement Mailing Fee: $ 1.00
Chargeback Fee: $ 25.00
Retrieval Fee: $ 15.00
Account Setup Fee: $ 199.00
Annual Fee: $ 99.00
Voice Authorization Fee: $ 1.00

See Terms and Conditions of Merchant Service Agreement for further information on Mid and Non-Qualified Surcharges.
I understand and acknowledge that I will be automatically enrolled in a 60-day free trial of the My Biz Perks Program, which includes
custom reporting and alerts, supplies, extended warranty, overnight replacement on equipment, partner discounts, and more! At the end
of the trial, I understand that my account will be charged a monthly membership fee, and I may opt out at any time by visiting
www.mybizperks.com or call 877-898-1992.
Initial
Revision 12/13 Here Page 10 of 11
 CARDHOLDER DATA STORAGE COMPLIANCE & SERVICE PROVIDER
** PCI DSS and card association rules prohibit storage of track data under any circumstances. If you or your point of sale (POS) system pass, transmit, store
or receive full cardholder's data, then the POS software must be PA DSS (Payment Application Data Security Standard) compliant or you (merchant) must
validate PCI DSS compliance (see 1(b) below and questions 3 and 4 must be completed). If you use a payment gateway, they must be PCI DSS compliant.**
1.Have you ever experienced an Account Data Compromise "ADC"? Yes No If yes, provide date of compromise
a) Have you validated PCI DSS (Payment Card Industry Data Security Standard) compliance? Yes No If yes, go to 1(b); If no, go to #2
b) Date of compliance, Report on Compliance "ROC" or Self Assessment Questionnaire "SAQ"?
c) What is the name of your Qualified Security Assessor "QSA" or Self Assessment Questionnaire(pick one) A B
d) Date of last scan Approved Scanning Vendor's name: C D
2.Are you using a "dial-up" terminal or "TTC" Touch Tone Capture? Yes No
3.Do you or your Service Provider(s) receive, pass, transmit or store the Full Cardholder Number "FCN", electronically? Yes No
a) If yes, where is card data stored? Merchant's Location Only Merchant's Headquarters/Corp office only Primary Service Provider
Both Merchant and Service Provider(s) Other Service Provider All Apply
4.What Primary Service Provider/Software Developer did you purchase your point of sale "POS" application from (e.g., software,gateway)?
a) What is the name of the Service Provider/Software Developer's application? Software Version #?
b) Do your transactions process through any other Service Provider (e.g., web hosting companies, gateways, corporate office)? Yes No
c) If yes, name the other Service Provider?

AMERICAN EXPRESS
By signing below, I represent that I have read and am authorized to sign and submit this application on behalf of the entity above and all information I have
provided herein is true, complete, and accurate. I authorize American Express Travel Related Services Company, Inc. (“American Express”) to verify the
information in this application and receive and exchange information about me personally, including by requesting reports from consumer reporting agencies.
I authorize and direct American Express to inform me directly, or through the entity above, of reports about me that American Express has requested from
consumer reporting agencies. Such information will include the name and address of the agency furnishing the report. I understand that upon American
Express’ approval of the entity indicated above to accept the American Express Card, the terms and conditions for American Express® Card Acceptance
(“Terms and Conditions”) will be sent to such entity along with a Welcome Letter. 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 Terms and Conditions.

Merchant's Signature ______________________________________ Alma Katia De Melgar

Name (printed): _______________________________________

Title: ______________________________________ Date: _______________________________________

MERCHANT ACCEPTANCE
A copy of the Card Services Terms and Conditions, revision number 12/13, has been provided to you. Please sign below to signify that you have received
a copy of the Card Services Terms & Conditions and that you agree to all terms and conditions contained therein. 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 and Merchant Service
Agreement ("Agreement"), which terms and conditions are hereby acknowledged and agreed to by the Merchant, and certifies that all information provided
in this Merchant Application is true, correct and complete. In addition by your signature below on behalf of Merchant you authorize Global Direct and/or
Member to order a consumer credit report on you, Merchant and each of Merchant’s officers, partners, and/or owners, as well as subsequent consumer
credit reports, which 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 other legitimate purposes associated with the Merchant account. The undersigned, on behalf of
the Merchant, authorizes (i)Global Direct, or (ii)the Member, or (iii)solely with respect to uncollected merchant fees, and subject to and only as pursuant to
North American Bancard's separate written agreement with Global Direct, North American Bancard, or, (iv)solely with respect to supplies and/or hardware
related to merchant business under this Merchant Application, North American Bancard, to initiate automated deposit or debit (ACH) entries to the
Merchant's bank account as indicated on this Merchant Application or subsequently provided by Merchant. A MERCHANT’S SUBMISSION OF A
TRANSACTION TO GLOBAL DIRECT SHALL BE DEEMED TO SIGNIFY MERCHANT’S ACCEPTANCE OF THE AGREEMENT, INCLUDING THE TERMS
AND CONDITIONS HEREIN.
_________________________________________________________ _________________________________________________________
#1 From Application - Signature Date #2 From Application - Signature Date
INDIVIDUAL GUARANTY (NO TITLES) I/We hereby irrevocably guarantee to Global Direct and Member, their successors and assigns, the full, prompt and
complete performance of Merchant and all of Merchant's obligations under this Agreement, including, but not limited to, all monetary obligations arising out of
Merchant's performance or nonperformance under this Agreement, whether arising before or after termination of this Agreement. The guaranty shall not be
discharged or otherwise affected by any waiver, indulgence, compromise, settlement, extension of credit, or variation of terms of this Agreement made by or
agreed to by Global Direct, Member, and/or Merchant. I/We hereby waive any notice of acceptance of this guaranty, notice of non-payment or
non-performance of any provision of this Agreement by Merchant, and all other notices or demands regarding this Agreement. I/We agree to promptly provide
to Global Direct and Member any information requested by either of them from time to time, concerning my/our financial condition(s), business history,
business relationships and employment information. I/We agree that Global Direct and Global Direct (on behalf of Member) may order a consumer credit report
on me, Merchant and each of Merchant's officers, partners, and/or owners, as well as subsequent consumer credit reports, which may be required or used in
conjunction with the maintenance, updating, renewal or extension of the services provided hereunder, or in conjunction with the reviewing, taking collection
action on, or other legitimate purposes associated with the Merchant Account. I/We have read, understand, and agree to be bound by the terms and conditions
contained in this Agreement on pages 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11.

________________________________________________________
For Office Use Only
#1 From Application - Signature Date X__________________________________________________
Application Accepted by ISO Date
________________________________________________________ X__________________________________________________
#2 From Application - Signature Date Accepted by Wells Fargo Bank Date
X__________________________________________________
Accepted by Global Direct Date

Revision 12/13 Page 11 of 11

MID#:

DBA NAME: La Reyna De Oros Market

SPECIAL PRICE REQUEST - GBL
DISCOUNT FEES

Tier 1 %
Visa/ MasterCard/Discover* **** "Qualified Rate" ****
*Includes Discover only if Discover Full Acquiring Account (funded with V/MC Transactions)
MasterCard CheckCards %

Visa CheckCards %

Discover CheckCards %

Reward Level 1 %

Tier 2 PLUS (+) % + $ per item

Visa/MC/Discover **** "Mid-Qual Rate" ****

Tier 3 PLUS (+) % + $ per item

Visa/MC/Discover **** "Non-Qual Rate" ****
~~ OR ~~
Interchange Plus Assessments + Basis Points

OTHER FEES
Transaction Fee: $ Wireless Transaction Fee: $

Per Item Pass Through Credit: $ Wireless Access Fee (Monthly): $

Per Item Pass Through Debit: $ Wireless Activation Fee: $

Amex Trans. Fee**: $ Internet Transaction Fee: $

** Includes Discover only if Discover Direct Account (Funded by Discover)

Address Verification (AVS): $ Internet Gateway Fee (Monthly): $

Batch Header Fee: $ Phone Swipe Transaction Fee $

DialPay (Touch Tone Capture): $ Phone Swipe Access Fee (Monthly) $

Voice Authorization Fee: $ PhoneSwipe Add'l Gateway(Monthly) $

Statement Fee: $ Debit Transaction Fee: $

Monthly Minimum Discount: $ Debit Gateway Fee (Monthly): $

Annual Fee: $ EBT Transaction Fee: $

Set Up Fee: $ Retrieval Fee: $

Daily/Weekly Reporting Fee: $ Chargeback Fee: $

Terminal Rental (Monthly) $ MyBizPerks Program: $

Terminal Rental is 1 Year to Own

Assessment Fees *** Pass Bundle Network Access Fees **** Pass Bundle
*** Visa/MC 0.11%, Disc 0.10% **** Visa $0.0218, MC $0.0198, Disc $0.0185

/ / / /
Merchant Signature Date PPT Signature Date
FREE TERMINAL
PLACEMENT AGREEMENT
FREE Verifone VX510 Terminal or VX510 w/ CR1000i Check
Imager
- Superior performance for faster transaction processing
- Ethernet connection for lightning-fast transactions
- Multiple payment and value-added applications
- PCI PED approved, advanced security including SSL
- Lower cost, higher performance
- Small size keeps countertops clutter free

FREE Verifone VX510 Terminal or VX510 w/ CR1000i Check

Imager
This Agreement is a contract between the Merchant named below and PAYMENT PROCESSING TECHNOLOGIES, LLC. (PPT).
NOW THEREFORE, Payment Processing Technologies (PPT) and the Party (Merchant) agree as follows:

I. Merchant agrees that the Equipment is the property of PPT, is being licensed to Merchant, and must be returned in good and working
condition within ten (10) days of the termination or expiration of the Merchant Account with PPT. If the Equipment is not returned
within ten (10) days, Merchant agrees to pay the equipment value (Vx510 = $895, Vx510 Combo with check imager = $1345, Vivotech
$299, Pinpad $100). Merchant authorizes PPT to ACH my account for said fees according to program. In addition, Merchant agrees
to be responsible for any damage to the Equipment as a result of misuse or negligence. PPT reserves the right to replace the above
models with comparable models and to add or discontinue models.

II. Merchant agrees to indemnify and hold PPT harmless from and against any and all liabilities, losses, claims, damages, disputes,
offsets, claims or counterclaims of any kind in any way related to the use (or misuse) of the Equipment. Merchant understands that
PPT agrees to free overnight delivery of replacement equipment, fully programmed and ready to use, up to but not exceeding twice
the first year, and that each additional incident will incur a fee of $99.

Merchant has accepted the following equipment (the “Equipment”) by checking one box below:
Select Connection Type:
Verifone Vx 510 Terminal (equipment value of $895)
Dial Up Connection
Verifone Vx 510Terminal, CR 1000i Check Imager, Stacker, and all necessary cables IP Connection (Cable/DSL)
(equipment value of $1345)

Verifone Pinpad 1000SE and necessary cables (equipment value of $100) – requires monthly $5 ISP Provider
debit gateway fee
ISP Phone Number
Vivotech (equipment value of $299)

Except as herein otherwise expressly provided, the Merchant Agreement, as heretofore amended, shall remain in full force and effect.

Merchant’s Authorized Signer: PPT:

____________________________________ ________________________________
Owner’s or Officer’s Signature Date Account Executive Signature Date

INDIVIDUAL GUARANTY (NO TITLES) I/We hereby guarantee to PPT, their successors and assigns, the full, prompt and complete
performance of Merchant and all of Merchant's obligations under this Agreement, including, but not limited to, all monetary obligations
arising out of Merchant's performance or nonperformance under this Agreement, whether arising before or after termination of this
Agreement. The undersigned, by signing below, agrees to be bound by the Agreement and this Guaranty.
Alma Katia De Melgar
______________________________________ ________________________________
Personal Guarantor Printed Name Date Personal Guarantor Signature Date
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SuperiorProcessingSolutions, Inc. BusinessReviewinVanNuys, CA http://www.la.bbb.org/business-reviews/Merchant-Credit-Card-Processi...

Home>BusinessorCharityReviews>MerchantCreditCardProcessingServices>SuperiorProcessingSolutions,Inc.

Revisión de Empresa BBB

¿Qué es una revisión de empresa BBB?

EMPRESA CON ACREDITACIÓN Q

BBBDESDE02/03/2011

Superior ProcessingSolutions,
Inc. C
(888) 770-3925
14426Victory Blvd.,VanNuys,CA91401
http://www.superiorprocessingi...

En una escala deA+hastaF

Razón para calificar
Resumen del sistema de
calificación BBB

Compartir Imprimir

Descripción
El negocio de esta empresa es brindar servicios de procesamiento de tarjetas de crédito.

Solicitar una Cotización

Solicite una cotización deSuperiorProcessingSolutions,Inc.

Acreditación BBB
Empresa con acreditación BBB desde03/02/2011.

BBB determinó que esta empresa cumple con las normas de acreditación BBB, que incluye el
compromiso de realizar un esfuerzo para resolver cualquier queja que tenga el consumidor. Las
empresas con acreditación BBB pagan una tarifa por revisar y dar seguimiento a la acreditación, y
para respaldar los servicios BBB ante público.

La acreditación BBB no significa que los servicios productos o servicios de la empresa se evaluaron,
que son respaldados por BBB, o que BBB ha hecho una determinación en cuanto al desempeño o
calidad de los productos de la empresa.

ReasonforRating
La calificación BBB se basa en 16 factores.Obtenga los detalles de los factores mencionados.

Factores que disminuyeron la calificación de esta empresa:

1 of2
SuperiorProcessingSolutions, Inc. BusinessReviewinVanNuys, CA http://www.la.bbb.org/business-reviews/Merchant-Credit-Card-Processi...

Desde cuánto tiempo la empresa ha estado trabajando

Factores que incrementaron la calificación de esta empresa:

Volumen de quejas registradas con BBB para empresas de este tamaño

Respuesta a las quejas registradas contra esta empresa
Solución a las quejas registradas contra esta empresa
BBB tiene suficiente información de fondo sobre esta empresa

Resumen de quejas de los clientes

0quejas cerradas con BBB en los últimos 3 años |0cerradas en los últimos 12 meses

Tipo de queja Total de quejas cerradas

Publicidad/Problemas de venta 0

Facturación/Problemas de cobro 0

Problemas con el producto/Servicio 0

Problemas de entrega 0

Garantía /Problemas de garantía 0

Total de quejas cerradas 0

Información adicional de quejas

Nuestros registros de quejas con esta empresa muestran que la única queja que llamó la atención de la
empresa se respondió y se le dio un seguimiento adecuado.

Detalles de la queja|Definiciones|Proceso de queja BBB|Levantar una queja

Acciones gubernamentales
BBB no tiene información que involucren acciones gubernamentales hasta el momento.

¿Qué tipo de acciones gubernamentales informa BBB?

Revisión de publicidad
BBB no tiene información que involucre la revisión de publicidad hasta el momento.

¿Qué es una revisión de publicidad BBB?

Información Adicional

Registro BBB abierto el: 12/11/2011

La empresa comenzó el: 13/11/2005

Información de contacto
RichardHuichapa–Director General

Número de empleados

2 of2
 ADDITIONAL NOTES
CONECTION VIA INETRNET