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Mail/Telephone Order/ Business to Business / Internet Information (All questions must be answered)


Academic year: 2021

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Blackstone Merchant Services is a registered ISO/MSP of Wells Fargo Bank, N.A., Walnut Creek, CA





Client’s Business Name (Doing Business As): Client’s Corporate/Legal Name (Use Also For Headquarter’s Information): Business Address: Billing Address (If Different Than Location Address):

City: State: Zip: City: State: Zip:

Location Phone #: Location Fax: Contact Name:

Business E-mail Address: Contact Fax # / E-mail Address:

Business Website Address: Contact Phone #:

Customer Service Ph # Customer Service E-Mail Address: Send Retrieval Requests to: o Business Location o Corp/Legal Location Send Merchant Monthly Statement to: o Business Location o Corp/Legal Location

o Individual/Sole Proprietorship: State in which Certificate of

ASSUMED NAME FILED: ________________________________ STATE: _______

o TAX EXEMPT ORGANIZATION (501C) State:_______________ o GOVERNMENT (Federal, State, Local)


Location Filed:________________________________________

o LIMITED LIABILITY COMPANY State Filed:__________________________


o MEDICAL OR LEGAL CORPORATION STATE: o ASSOCIATION/ESTATE/TRUST State Filed_______________ o PARTNERSHIP State Filed:__________ Name (as it appears on your income tax return): FEDERAL TAX ID #

(as it appears on your income tax return) o I certify that I am a foreign entity/ nonresident alien (If Checked please attach IRS Form W-8)

NOTE: Failure to provide accurate information may result in a withholding of merchant funding per IRS regulations (See part IV, Section A.4 of your Program Guide for further information.) SIC/MCC: Detailed Explanation of Type of Merchandise, Products or Services Sold:

2. ADDITIONAL CREDIT / SITE SURVEY INFORMATION - ALL MERCHANTS Are you using a vendor? o Yes o No If yes please supply a copy of Vendor’s report.

Merchant Initials: Rev.132406

1. Zone: o Business District o Industrial o Residential

2. Location: o Mall o Office o Home o Shopping Area

o Mixed o Apartment o Isolated 3. How many employees: ______________________ 4. How many registers / terminals: ______________ 5. Is proper license visible? o Yes

No,explain: ________________________________________________________________ 6. Where is the merchant name displayed at the site?

o Window o Door o Store Front

7. Merchant Occupies: o Ground Floor o Other: __________________________ 8. # Of Floors/Levels: o 1 o 2-4 o 5-10 o 11+

9. Remaining Floor(s) Occupied by:

o Residential o Commercial o Combination 10. Approximate Square Footage:

o 0-250 o 251-500 o 501-2,000 o 2,001 plus 11. Are customers required to leave a deposit?

o No o Yes If Yes, % of deposit required: ______ % 12. Return Policy: o Full Refund o Exchange Only o None

13. Do you have a refund policy for MC/Visa/Discover® Network/American Express

OnePoint Sales? o Yes o No If yes, check one.

o Exchange o Store Credit o MC/Visa/Discover® Network Credit

o American Express OnePoint Credit?

If MC/Visa/Discover®Network/American Express One Point Credit within how many days do

you submit credit transactions? o 0-3 o 4-7 o 8-14 o Over 14

14. Advertising Method (Attach at least one):

o Catalog o Brochure o Direct Mail o TV/Radio

o Internet o Phone o Newspaper/Journals o Other

Marketing Materials required for Mail Order, B to B, Internet over $1 Million in annual volume. Attach Web Page for Internet Merchant.

15. Your Previous Processor: _______________________________________________________________________ 16. Check Reason For Leaving:

o Rate o Service o Terminated Date: o Other: __________________________________

Mail/Telephone Order/ Business to Business / Internet Information

(All questions must be answered) 1. What % of total sales represent business to business (vs business to consumer):

Business to Business________% + Business to Consumer________% = 100% (total sales) 2. What % of bankcard sales represent business to business (vs business to consumer):

Business to Business________% + Business to Consumer________% = 100% (total sales) 3. What is the time frame from transaction to delivery? (% of orders delivered in):

0-7 days_______% + 8-14 days_______% + 15-30 days______% + over 30 days ______% = 100% 4. MC / Visa / Discover® Network / American Express OnePoint sales are deposited (check one):

o Date of order o Date of delivery o Other (specify) ______________________________________

5. Who performs product / service fulfillment? o Direct o Vendor o Other If vendor, add Name: _____________________________________________________________________________________ Address: ___________________________________________________________________________________ City/State/Zip:________________________________________ Phone:________________________________ Please describe how the transaction works, from order taking to merchant fulfillment

(attach additional sheet if necessary):

6. Does any of your cardholder billing involve automatic renewals or recurring transactions (i.e. cardholder authorizes initial sale only)? o Yes o No

Sales Office ______________________________________ Print Sales Rep Name ___________________________________________________________________ Sales ID# __________________________________ Merchant Number _________________________________ Sales Rep Signature ____________________________________________________________________ Phone# ____________________________________ Page 1 of 4


Blackstone Merchant Services is a registered ISO/MSP of Wells Fargo Bank, N.A., Walnut Creek, CA

Blackstone1605 3. COMPANY HISTORY Blackstone1605(ia)

Date Business Started: Prior Bankruptcies? o No o Yes o Business and / or o Personal


Vendor Name: Vendor Name:

Address: Address:

City: State: Zip: City: State: Zip:

Contact Name: Contact Phone #:

Customer Service Ph # Vendor Acct. #: Contact Telephone #: Vendor Acct. #:



Name: (First, Mi, Last) % Ownership Name: (First, Mi, Last) % Ownership

Title: Title:

Home Address: (No P.O. Box) Home Address: (No P.O. Box)

City State: Zip: Country: City: State: Zip: Country:

Telephone #: Social Security #: Telephone #: Social Security #:

D.O.B.: DL #: State: D.O.B.: DL #: State:


Deposit Bank: Bank Contact #:

Transit / ABA #: Deposit Account #:

ACH Detail Flag: o Individual o Combined o Separate (defaults to combined if option not selected)

6. EQUIPMENT/THIRD PARTY INFORMATION Network (Front End): o Omaha o North o Nashville o BuyPass

Do you use any third party to store process or transmit cardholder data? o Yes o No

If yes, give name/address: __________________________________________________________________________________________________________________________________________ Please identity any Software used for storing, transmitting, or processing Card Transactions or Authorization Requests: ________________________________________________________________ INTERNET GATEWAY: o Blackstone Gateway Other: ________________________________________ Wireless Network: ______________________________________________________ PC/Internet Software _____________________________________________________ Quantity ____________ o Purchase $ ____________ o Lease o Reprogram

Terminal Model oPax S80 Other __________________________________ Quantity ____________ o Purchase $ ____________ o Lease o Reprogram POS System oHioPOS Other (See Service Agreement) o Purchase $ ____________ o Lease o Reprogram PIN Pad _____________________________________________________________ Quantity ____________ o Purchase $ ____________ o Lease o Reprogram LEASE COMPANY: (04) First Data Global Leasing Lease Term:______ Mos. Annual Tax Handling Fee: 10.20

Total Monthly Lease Charge: $____________ w/O taxes, late fees, or other charges that may apply – See Lease Agreement in Program Guide for details. This is a non-cancelable lease for the full term indicated.

Address: City: State: Zip: Attention:




(Must = 100%) Gross YEARLY Sales Vol. (Cash + Credit + Debit + Check) $ ______________ Average MC/Visa/Discover® Network Ticket $ ______________

(Estimate if Never Processed in Past) Store Front/Swiped ________________ % Average YEARLY MC/Visa/Discover Volume $ ______________ Avg. Pin Debit Ticket $ ______________ eCommerce ________________ % Average YEARLY Pin Debit Volume $ ______________ Avg. American Express OnePoint Ticket $ ______________ Mail/ Telephone Order ________________ % Average YEARLY American Express One Point Volume $ ______________ Highest Ticket Amount $ ______________

Seasonal? o No o Yes High Volume Months Open: ______________________________________________________________________________________ TOTAL ________________ % Authorization Grid ID# _________________________________ Tiered Discount Grid# ________________________________ User Defined Grid# ___________________________________

Merchant Initials: Rev.132406

DBA Name: ___________________________________________________________________________________________ Merchant #: ___________________________________________ Page 2 of 4


Blackstone1605 9. SERVICE FEE SCHEDULE Blackstone1605(ia) Authorization & Capture Transaction Fees

TransArmor Auth Fee $ _______ (Per Item) Voice Authorization Fee $ _______ (Per Item) Electronic AVS Fee $ _______ (Per Item) Voice AVS Fee $ _______ (Per Item) ARU Fee $ _______ (Per Item)

Monthly Fees

Monthly Statement Fee $ ________ Monthly Minimum Fee $ ________ Reg. Product Fee $ ________ Customer Service Fee $ ________ Debit Access Fee $ ________

PCI Fee $ ________

eIDS Online Chargeback Fee $ ________ Portfolio Mgr Fee o Yes o No $ ________ Wireless Fee $ ________ Website Usage $ ________

IVR Usage $ ________

Other: $ ________ Only If Applicable Non PCI Compliance Fee $ ________ TIN/TFN Invalid $ ________ MasterCard, Visa and Discover Network Authorization & Capture Fee: $ __________ (Per Item)

Miscellaneous Fees

o Dues & Assessments Chargeback Fee $ ______ (Per Item) Retrieval Fee (12B Letter) $ ________ (Per Item) Return Trans. Fee $ ________ (Per Item) Setup Fee: o ACH o Check $ _________ Batch Fee $ ________ (Per Item) Early Termination Fee $ _______

EBT – Food Stamps

$ _______ (Per Item) #: __________________

EBT – Cash Benefits $ _______ (Per Item)


________________________ $ ________ AnnualSupport Fee $ _______ Wireless Setup Fee: $ ___________ Check Setup Fee: $ ___________ Gift Card Setup Fee: $ _______

Visa Processing Fees MasterCard Processing Fees Discover Processing Fees 3 Pass Visa ACQ ISA Fee:

3 Pass Visa Acquirer Processing Fee.

3 Pass Visa Misuse of Authorization Fee.

3 Pass Zero Floor Limit Fee.

3 Pass Visa International Acquirer Fee

3 Pass Visa International Acquirer Network Fee (FANF).

3 Pass Visa International Integrity Fee.

3 Pass MC Acquirer Support Fee.

3 Pass MC Cross Border Fee.

3 Pass MC National Acquirer.

3 Brand Usage (NABU) Fee.

3 MC Processing Integrity Fee.

3 Pass Discover International Processing Fee.

3 Pass Discover International Service Fee.

3 Pass Discover Data Usage Charge.

Accept all MasterCard, Visa and Discover Network Transactions

(presumed, unless any selections below are checked)

MasterCard Acceptance Visa Acceptance Discover Network Acceptance AMEX OnePoint Acceptance

o Accept MC Credit Transaction only

o Accept MC Non-PIN Debit Trans. only o o Accept Visa Credit Transactions Accept Visa Non-PIN Debit Trans. only


o Accept Discover Network Credit Transaction only

o Accept Discover Network Non-PIN Debit Transaction only

o Accept AMEX Credit Transaction


See Section 1.9 of the Program Guide for details regarding limited acceptance.

o Discount Collected o Daily o Monthly

15.00 10.00


n Tiered Discount Fees (Based on Gross Sales Volume) n ERR PIN Debit n Yes n No Discount Discount Non-Qual Fees o Pass Through Debit Network Fees

MC/Visa/Discover Network Qual Credit % MC/Visa/Discover Qual Credit % % Other Item Rate $ __________ (per item) MC/Visa/Discover Network Mid-Qual Credit % MC/Visa/Discover Qual Debit % % Other Volume Percent $ __________ (per item)

MC/Visa/Discover Network Non-Qual Credit % % %

MC/Visa/Discover Network Qual Debit % n Pass Through Interchange - Includes Dues and Assessments Fleet

MC/Visa/Discover Network Mid-Qual Debit % Plus Discount

(Based on Gross Sales Volume)

Wright Express:

MC/Visa/Discover Network Non-Qual Debit % Other Item Rate $ _______________ (per item)

MC/Visa/Discover Network Regulated Debit % MC/Visa/Discover Qual Credit % Voyager:

MC/Visa/Discover Qual Debit % Qual _______________% $ _______________ (per item)

0.30% downgrade will be charged by American Express for transactions whenever a CNP or Card Not Present Charge occurs including Prepaid Cards. CNP means a Charge for which the Card is not presented at the point of purchase (e.g., Charges by mail, telephone, fax or the Internet). NOTE: The CNP Fee is applicable to transactions made on all American Express Cards, including Prepaid Cards for Retail, Restaurant, and Travel Agencies/Tour Operators key-entered programs.

An Inbound fee of .40% will be applied to any charge made using a card, including Prepaid Cards, issued by an issuer located outside of the United States (the United States does not include Puerto Rico, the U.S. Virgin Islands and other U.S. territories and possessions) except MCC 7032, 8211, 8351, and 8220 card transactions.

American Express Card Acceptance

Would you like to process American Express? o Yes o No

Existing Amex Merchant Account Number_________________________________________

o American Express OnePoint/Full Service (EDC) or o American Express ESA/Passthrough* AMEX Discount Rate ________ % Transaction Fee $ _____

AMEX Prepaid Discount Rate ________ % Transaction Fee $ _____

*American Express will charge a flat fee of $ ________ or a discount rate to the merchant.


o Split Dial o License # o MICR o ECA Warranty

o Mail Order o Hold Check o Paper Warranty o C.O.D. SE Number__ __ __ __ __ __ __ __ __

TeleCheck Rates & Fees n Yes n No Inquiry Rate ____________ % Stmt/Processing Fee $ _____________ Dec. Risk Surcharge ____________ % ACH Processing Fee $ _____________ Per TXN Fee $ _____________ Client Requested

Operator Call (CROC) $ _____________

Minimum Monthly Fee $ _____________ (Per Location)

ECA Chargeback Fee $ _____________ (only charged when entitled with TeleCheck) See Agreement for definitions, warranty requirements and any additional fees.

Merchant Initials: Refer to Program Guide

Section A.3


DBA Name: ___________________________________________________________________________________________ Merchant #: ___________________________________________ Page 3 of 4

















Blackstone Merchant Services, LLC is a registered ISO/MSP of Wells Fargo Bank, N.A., Walnut Creek, CA


Blackstone1605 10. SIGNATURE (S) Blackstone1605(ia)

Blackstone Merchant Services is a registered ISO/MSP of Wells Fargo Bank, N.A., Walnut Creek, CA Rev.132406

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 Blackstone1605) and Confirmation Page, which is part of this Merchant Processing Application (consisting of Sections 1-10), and by this reference incorporated herein. Client hereby consents to receiving commercial electronic mail messages from us or our Affiliates from time to time. Client further agrees that Client will not 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 8,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, TeleCheck Services 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 TeleCheck Services Agreement and American Express® Card Acceptance Agreement. Client authorizes Blackstone Merchant Services (“BMS”) and Wells Fargo Bank, N.A. (“Bank”) and their Affiliates 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 named in this Merchant Processing Application. Client authorizes BMS and BANK and their Affiliates (a) to procure information from 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 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.

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 Blackstone Merchant Services (BMS) 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 from time to time, and disclose such information to their agent, subcontractors, Affiliates and other parties for any purpose permitted by law. I authorize and direct BMS and AXP and AXP’s agents and Affiliates to inform me directly, or inform the entity above, about the contents 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 on me from consumer reporting agencies for marketing and administrative purposes. I am able to read and understand the English language. I understand that upon AXP’s approval of the application, the entity will be provided with the Agreement and materials welcoming it either to AXP’s program for BMS to perform services for AXP or to AXP’s standard Card acceptance program which has different servicing terms (e.g. different speeds of pay). I understand that if the entity does not qualify for the BMS servicing program that 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 BMS and Bank and their affiliates to debit Client’s designated bank account via Automated Clearing House (ACH) for costs associated with 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, or processing and acceptance of transactions in certain jurisdictions pursuant to 31 CFR Part 500 et seq. and other laws enforced by the Office of Foreign Assets Control (OFAC). 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 BMS and Bank.

Personal Guarantee: In exchange for Blackstone Merchant Services Corporation,Wells Fargo Bank, N.A., American Express and TeleCheck Services, Inc. (the Guaranteed Parties) acceptance of, as applicable, the Agreement, and/or the Equipment Lease Agreement and/or the American Express Card Acceptance Agreement and/or the TeleCheck /TRS Services Agreement, the undersigned unconditionally and irrevocably guarantees the full payment and performance of Client’s obligations under the foregoing agreements, as applicable, as they now exist or as modified from time to time, whether before or after termination or expiration of such agreements and whether or not the undersigned has received notice of any amendment of such agreements. The undersigned waives notice of default by Client and agrees to indemnify the Guaranteed Parties for any and all amounts due from Client under the foregoing agreements. The Guaranteed Parties shall not be required to first proceed against Client to enforce any remedy before proceeding against the undersigned. This is a continuing personal guaranty and shall not be discharged or affected for any reason. The undersigned understands that this is a Personal Guaranty of payment and not of collection and that the Guaranteed Parties are relying upon this Personal Guaranty in entering into the foregoing agreements, as applicable. Client’s Business Principal/Officer:

Signature X _________________________________________________________ Title _______________________________ Print Name of Signer _________________________________ Date __________ Signature X _________________________________________________________ Title _______________________________ Print Name of Signer _________________________________ Date __________

Personal Guarantee

Signature X ____________________________________________________________________ Print Name: ___________________________________________________________ Date ________________ Personal Guarantee

Signature X ____________________________________________________________________ Print Name: ___________________________________________________________ Date ________________

Telecheck ACH Authorization:

ACH Debit and Credit Authorization: Client authorizes its Financial Institution to pay and charge to its account the amount(s) due TeleCheck under this TeleCheck Agreement and to accept all credits and debits made to its account by TeleCheck via electronic funds transfer in connection with TeleCheck’s services under this TeleCheck Agreement.This authorization shall remain in effect until (30) thirty days after revoked in writing.

Signature X ____________________________________________________________________ Print Name: ___________________________________________________________ Date ________________ Authorized Signature on TeleCheck Account for ACH

DBA Name: ___________________________________________________________________________________________ Merchant #: ___________________________________________ Page 4 of 4

Accepted By Blackstone Merchant Services, Inc. Wells Fargo Bank, N.A., Walnut Creek, CA 94598 Personal Guarantee

Signature X____________________________________________________________________ Signature X __________________________________________________________

Title ____________________________________________________ Date ________________ Title ________________________________________________________________ Date ________________





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

(also referred to as your Settlement

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 or see the applicable provisions of the

TeleCheck Services Agreement.

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 or within 30 days of the date of a TeleCheck transaction.

5. The Agreement limits our liability to you.

For a detailed descrip

-tion of the limita-tion of liability see Sec-tion 20 of the Card Processing

General Terms; or Sec tion 1.14 of the Tele Check Services Agree ment.

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),

(see TeleCheck Services Agree ment in Sections 1.1, 1.3.2, 1.3.9, 1.6), 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 IV, A.3 under “Additional Fee Infor mation” and

Section 1 of the TeleCheck Services Agreement.

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.


10. Card Organization Disclosure

Visa and MasterCard Member Bank Information: Wells Fargo Bank N.A.

The Bank’s mailing address is 1200 Montego, Walnut Creek, CA 94598, and its phone number is (925) 746-4143.

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 Blackstone1605] con sist ing of 44 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:



Client’s Business Principal:


(Please sign below)






Title Date

_______________________________________________________________________________ Please Print Name of Signer

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:

http://usa.visa.com/merchants /operations/op_regulations.html

g) You may download “MasterCard Regulations” from MasterCard’s website at:





Address: _________________________________________________________________________________________________________________

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 or the contents of your

Agreement with TeleCheck. The following information summarizes portions of your Agreement in order to assist you in answering some of the

questions we are most commonly asked.

Blackstone Merchant Services, Inc.

11600 NW 34th Street, Miami, FL 33178



Services  Terminal  Setup  Form  

Merchant DBA


Business Information


Retail With Tips


Please Select the Business Type

General Parameters



Password Protection

Yes No

6 Digits Password

External Pin Pad


Debit Processing


EBT Processing


Prompt for Invoice Number During the Sale

Settlement (Closing)

Prompt for Customer Code During the Sale

Reprint Receipts

Allow Manual Transactions

Reports Menu

Debit Cash Back

EBT Balance Inquiry

EBT Cash Back

Open Batch Review


ast 4#’s of the card,

AVS & CVV2 are mandatory prompts


Tips & Clerks



Others Parameters

Yes No

Fill Only if “Yes”

Tip Processing

Auto Close


Prompt for Clerk or Server Number

Apply Tax Over Sale


Prompt for Tip at the Moment of the Sale

Allow Closing with Unadjusted Tips

NOTE: The TAX will increase the transaction amount

NOTE: Auto Close is not recommended if you work with Tips

Additional Services



Communication Mode

Select Only One

Store Gift Cards


Calling Cards & Cell Phone Recharges

Phone Line (No V/IP - No Magic Jack)

Check Processing (TeleCheck)

High Speed Internet (IP)

Prefix (Please fill this area Only if your communication mode is Phone Line)

Any Prefix Digit?

Some phone systems require a Prefix Digit to make a phone call (Usually 9 or 0)

Other Requirements Not Listed in this Form

Blackstone Representative

Printed Name:




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