QUICK APP
Sales Rep Name: _________________________________
Date: _________________________________
Sales Rep #:
_________________________________
Location # __________ of _________
BUSINESS INFORMATION
Corporate Name: _________________________________
Address:
__________________________________
City:
__________________________________
State:
_______________ Zip: ______________
Phone:
____________________________
Fax:
____________________________
Contact:
__________________________________
Contact Title:
__________________________________
Email:
__________________________________
Business Type:
Corporation Sole LLC GOV
Partner Non-Profit Tax Exempt
State of Incorporation _______ Date Started ___________
DBA Name:
__________________________________
Address:
__________________________________
City:
__________________________________
State:
_______________ Zip: ______________
Phone:
____________________________
Fax:
____________________________
Contact:
__________________________________
Contact Title:
__________________________________
Website:
__________________________________
Fed Tax ID:
__ __ __ __ __ __ __ __ __
Type of Goods Sold: _______________________________
OWNERS or OFFICERS
_________________________________
___________________
______ __________________ ___________________
Name:
Title:
Equity:
Applicant’s SS#:
Date of Birth
__________________________
__________________________
_____ ________________
___________________
Home Address:
City, State, Zip:
Years
Home Phone#:
Driver’s License #
BANK NAME:
__________________________________
Routing #:
___________________________
(9 Digits)
BANK PHONE #: __________________________________
ACCT #:
___________________________
ACCOUNT INFORMATION
Monthly Volume
Equipment
Qty
Type / Manufacturer
Percent of Business
(Must Be 100%)Card Swiped %
Keyed %
Keyed w/out Imprint %
Average Ticket
Terminal
High Ticket
POS
Sales Method
Store Front %
Off Premise %
Mail / Phone Order %
V//MC Rate
Gateway
Trade Show % Other % Internet %Trans Fee
Mobile
AMEX
> $1,000,000 Yes NoTSR
$
TERM
Current Gift Card Program?
Yes Vendor?
Reprogram
Placement
Equipment Purchase
© Copyright ClearPay Financial Solutions, 2011-2015
Version CPFS2aMerchant Payment Receipt
CLIENT INFORMATION
Date:
DBA Name
Address
City/State/Zip
Contact Name
Phone
Fax
DESCRIPTION / ITEM
COST
(EACH)QTY
CONDITION
SUB TOTAL
Purchase Membership Reprogram Lease
New
Refurbished
$
Purchase MembershipReprogram Lease NewRefurbished
$
Purchase MembershipReprogram Lease NewRefurbished
$
Purchase MembershipReprogram Lease NewRefurbished
$
Premium Price Guarantee
EMV Encryption |
Cancellation Fee Reimbursement Requested
*requires certificateSETUP FEES
Merchant Application and Enrollment Fee*
$ 125.00
Reprogramming and Conversion Fee*
$ 295.00
Shipping / Encryption*
$ 145.00
Data Transmission Setup Fee*
$ 11.00
Start Kit*
$ 12.50
SUB TOTAL $ 588.50
Equipment Purchase
(from above Sub Total): $____________________ X ( _______% tax) = $____________
$
TOTAL DUE
$
DEBIT / CREDIT AUTHORIZATION
Client hereby authorizes ClearPay Financial Solutions LLC to debit client’s checking account in accordance with this agreement. The authority is to
remain in full force until ClearPay Financial Solutions LLC has received written notification of its termination in such a manner as to afford ClearPay
Financial Solutions LLC reasonable opportunity to act on it; and all obligations of client to ClearPay Financial Solutions LLC have arisen under the
Agreement have been paid in full.
Depository Bank
Bank Phone #
City/State
Transit Router / ABA Number
Account Number
ATTACH VOIDED CHECK
PROCESSING FEES ARE NON-REFUNDABLE. ALL SALES ARE FINAL. RETURNED ITEMS ARE SUBJECT TO $25.00 CHARGE PER OCCURANCE. *Non-refundable processing fees. By signing below, you acknowledge to have read and agreed to the conditions contained herein, that you are an authorized signer for the
above mentioned entity, and agree to pay ClearPay according to the terms of this agreement.
MERCHANT SIGNATURE: ________________________________ Title ______________Date ___________
OFFICE USE ONLY
Rep Name
© Copyright ClearPay Financial Solutions, 2011-2014
Version CPFS1aP R E M I U M P R I C E & R A T E M A T C H
.
GUARANTEE
This PREMIUM PRICE GUARANTEE AGREEMENT (hereinafter “Agreement”) is made this _________ day of _______________,
20_____, by and between ClearPay Financial Solutions LLC, with principle offices at 10000 West Innovation Drive Ste 160, Milwaukee,
Wisconsin 53226 (hereinafter “COMPANY”) and ____________________________________________________________ , with its
principle offices at (address) _______________________ (city) ________________ (state) _____________ (zip) _________ (hereinafter
referred to as “MERCHANT” or, collectively, with COMPANY as the “Parties”)
PREMIUM PRICE GUARANTEE. COMPANY shall provide pricing as shown in the Merchant Processing Application, merchant agrees
to process its credit and/or debit card transactions exclusively with company for a term of 60 months. In consideration for the extended
term of the Merchant Processing Application, company guarantees that the discount rates reflected in the Merchant Processing
Application, will not be higher than _____ basis points above our interchange blended rate during the initial 60 month term of this
agreement. Merchant further acknowledges that no other agreements or stipulations have been made either verbal or otherwise and that
these agreements represent the entire agreement.
Merchant acknowledges and agrees that company and or its affiliates have the right to debit directly from merchant's accounts any and
all fees due in connections with and as stipulated to in the Merchant Processing Application and its addendums. Additionally, in
consideration for the extended term, COMPANY agrees to waive fees noted on the payment receipt. These fees are considered earned
on date of signing.
Merchant acknowledges that these fees represent costs to COMPANY, in the event that merchant terminates this agreement prior to the
contractual time limit of 60 months, all waived fees will become immediately due and payable to the company. Upon termination, merchant
authorizes COMPANY to immediately debit all amounts owed company from MERCHANT checking account electronically. Merchant
further acknowledges that company is not a representative of, or affiliated in any way with their current bank. Any lease agreements
entered into by merchant as a result of this or any other agreement will continue regardless of the processing status of the merchant with
company.
RATE MATCH GUARANTEE. COMPANY will match any legitimate companies quote in writing. Almost all merchant account providers
price their services differently and the intent of this description is to ensure that the price comparison and guarantee are a fair reflection
of costs to the merchant over the course of a year and not simply a rate(s). In order to take advantage of the guarantee, merchants must
provide either a complete schedule of fees from a verifiable competitor or two month's current processing statements along with the
original contract or agreement. If any fees are not stated clearly, we may ask that the merchant provide the information. We cannot honor
the guarantee if we are not provided with all requested information. When comparing costs, we will include all costs including, but not
limited to, any hardware, account set-up, statement, customer service, termination, PCI or annual fees. We will project these costs based
on the merchant's monthly charge volume, business type, credit history and any other pertinent factors in order to get the true costs of
each offer.
EQUIPMENT GUARANTEE. The equipment is hereby conditionally guaranteed for as long at MERCHANT is processing with COMPANY.
MERCHANT must maintain My Biz Perks program to qualify for equipment free equipment replacement. MERCHANT may choose to
upgrade their equipment at any time however any existing lease agreements will continue.
In the event the MERCHANT is not satisfied with COMPANY after attempting written communication with our customer service or any dispute or controversy arises between the Parties to this agreement, relating to this agreement, the lease confirmation and delivery/acceptance form, the equipment status form, the merchant processing application, stated estimated savings or the non-cancelable commercial lease agreement, whether directly or indirectly, said dispute or controversy shall be determined by final and binding arbitration. MERCHANT agrees that any dispute is private matter between the Parties and MERCHANT agrees to keep the dispute confidential. In the event any publically posted or written comments will be removed and retracted. Each party shall name an arbitrator within twenty (20) days after one party gives written notice to the other party of such a dispute or controversy. The two arbitrators shall select a third arbitrator with fifteen (15) days of their appointment. If any party fails to select an arbitrator within twenty (20) days after receiving written notice of a dispute or controversy, or if the two arbitrators fail to select a third arbitrator with fifteen (15) days after they have been appointed, then the presiding Judge of the Superior Court of Milwaukee County, Wisconsin shall appoint such other arbitrator or arbitrators. The arbitrators shall render a decision within sixty (60) days after their appointment and shall conduct all proceedings pursuant to the Rules of the American Arbitration Association governing commercial transactions. Each party shall pay its arbitrator's fees and one half of the third arbitrator. Any other costs of arbitration including attorney's fees shall be paid by the party incurring said costs or fees. The parties agree that the arbitration procedure provided herein shall be the sole and exclusive remedy to resolve any controversy or dispute rising hereunder, and that the proper venue for such arbitration proceedings shall be in the City of Milwaukee, County of Milwaukee, and State of Wisconsin. The Parties specifically waive their right to seek remedies in court. Under no circumstances shall the arbitrator award consequential or exemplary damages. This arbitration provision shall survive the termination of this agreement and the termination of the transaction. In the event either party to this agreement is joined in a lawsuit by another party to the agreement, the party to the lawsuit joining the other party to this agreement shall hold the joined party harmless against any and all claims, losses, costs, expenses (including reasonable attorney's fees) damages or liabilities paid or asserted against the joined party.
MERCHANT:
Printed Name & Title
Signature
Date
OFFICE USE ONLY
Sales Rep Name© Copyright ClearPay Financial Solutions, 2011-2014
Version CPFS1aMerchant Application
SICC/MCC#:
Merchant ID:
Discover MID:
Routing #:
Acct #:
Account Type:
Checking
Savings
Average Ticket $:
% Not Present:
% Present:
Merchant Profile
No
Yes
Mo/Year:
Email:
Fax:
St:
Zip:
SS#:
City, State Zip:
Merchant Information
DBA:
Legal Name:
Address:
Contact Name:
Owner/Officer Information
Owner/Officer Information
Name:
Name:
% Ownership:
% Ownership:
SS#:
Home Address:
City:
St:
Zip:
Home Address:
City:
Phone:
Phone:
Sole Proprietor
Partnership
Nonprofit/Tax Exempt
Corporation
LLC
Government
Ownership Type:
State Incorporated:
Product/Service Sold:
Return Policy:
Website:
Accept or Previously Accepted Visa/MC/Discover:
Sales Profile
Transactions:
Annual Volume (MC/Visa/Discover) $:
Bank Information (Attach voided check)
Bank Name:
Name on Account:
Card Acceptance Profile
MC Credit
MC Debit
Visa Credit
Visa Debit
Pin Based Debit
AMEX
EBT
Association ID
Process eCommerce Transactions?
Yes
No
Seasonal Business?
Yes
No
If seasonal, specify months:
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Discover Credit
Discover Debit
Address:
City, State Zip:
Physical Address
Mailing Address (if different)
Phone:
Association/Estate/Trust
Prior Statements Available:
Yes
No
222 S. Central Ave, Suite 700, Clayton, MO 63105 | TEL 314 732 0515 | FAX 314 721 7300 | www.clearent.com
Clearent LLC is a registered ISO/MSP of
Central Bank of St. Louis | 7707 Forsyth Blvd, Clayton, MO 63105 | TEL 314 746 4642
v20141115
Page 1 of 5
Phone Number:
Site Survey
(to be completed by Sales Representative)
No
Yes
Retail
Store Front
Office Building
Industrial Building
Tradeshow
Other
Other Desc:
Site Photo Included?
Valid ID Verified?
Yes
No
0-250
Square Footage:
251-500
501-2000
2000 +
Merchant:
Owns
Leases
Landlord Name:
Is the Merchant open and actively conducting business with customers?
Yes
No
If not, please explain:
Is Inventory consistent with the type of business and stated sales volume?
Yes
No
Are goods and services delivered at the time of sale?
Yes
No
By signing below, I verify that (i) I have physically inspected the business premises or I verified the merchant via the phone which included
obtaining a copy of a valid picture ID, which I have included with the application, and that (ii) the information stated in this Site Inspection Form
is correct to the best of my knowledge and is as presented to me by the Merchant.
Sales Representative Signature:
Date:
Sales Representative Name (Please Print):
Residence
Did you conduct the site survey in person?
Yes
Outbound marketing (you contacted merchant)
Inbound marketing (merchant contacted you)
If not what % is future delivery:
If not, please explain:
No
If not, how did you find this merchant?
If Nurit Terminal, NOS Version:
Equipment Type:
PIN Pad:
Printer:
Check Reader:
Dial
Connectivity:
DSL
IP/Dial
Wi-Fi/Dial
Manual Imprinter:
Yes
No
Terminal Setup
Dial Prefix:
Call Waiting:
Tips:
Provider:
Sales Office
Merchant Owned
Processor
Auto Close Time:
Download Type:
Retail
Restaurant
Lodging
Cash Advance
Ship To:
Merchant
ISO/Sales Agent
Office
Other (Specify):
Ship Method:
Overnight
2nd Day
Ground
Zip:
State:
City:
Address:
Location Name:
No
Yes
Equipment Information
Comments:
Host Capture
Terminal Capture
Terminal Capture Type:
TSYS Wireless
222 S. Central Ave, Suite 700, Clayton, MO 63105 | TEL 314 732 0515 | FAX 314 721 7300 | www.clearent.com
Clearent LLC is a registered ISO/MSP of Central Bank of St. Louis | 7707 Forsyth Blvd, Clayton, MO 63105 | TEL 314 746 4642
v20141115
Page 2 of 5
Pricing
Fee
Rate
%
$
IC Plus: Interchange, Dues, Fees & Assessments
$
N/A
American Express
$
N/A
EBT
Other Fees
$
N/A
Other Fee:
$
N/A
Other Fee:
$
N/A
Other Fee:
$
N/A
Other Fee:
Settlement:
Daily
Monthly
%
$
PIN-Based Debit
Pass through network fees?
Host Capture Administrative Transaction Fee
N/A
$
%
Express Merchant Funding:
N/A
Month(s)
Fee
$
N/A
Authorization Fee
$
N/A
IVR / DialPay Authorization
$
N/A
Voice Authorization
$
N/A
AVS Transactions (Surcharge)
$
N/A
Batch Processing
$
N/A
Chargeback Item Processing
$
N/A
Retrieval Item Processing
$
N/A
Non Supported Help Desk Call
$
Application Processing Fee
$
Annual Fee
$
Semi-Annual Fee
** Two Months Required
$
N/A
Debit Access Fee
$
N/A
Gross Settlement Fee
$
N/A
Monthly Account Fee
$
N/A
Monthly Compass Online Reporting
$
N/A
Monthly Minimum Discount
$
N/A
Monthly Statement
$
N/A
Monthly Supply Club Membership
Monthly Statement:
Tax Forms:
Online Only
Online Only
Online + Paper
Online + Paper
Secondary Authorized Signer:
By signing below on behalf of the merchant described above (“Merchant”) the undersigned individual(s) hereby: (i) Represents and warrants that all information contained in this application is true, correct and complete and that such individual(s) have the requisite power and authority to complete, submit and agree to the terms of this Merchant Application and the Merchant Agreement (collectively the “Agreement”) on behalf of themselves and Merchant; (ii) confirms that Merchant has reviewed and agrees to be bound by the terms and conditions of the full Agreement; (iii) authorizes Bank and Clearent to request a consumer credit report or reports from one or more consumer reporting agencies; (iv) agrees to allow the Bank and Clearent the right to conduct a physical inspection of Merchant’s business premises to assure that the proper facilities, equipment, inventory, and necessary license or permit are present to conduct business; (v) authorizes the Bank, Clearent or their agents to initiate credit and/or debit entries to the account identified in this Merchant Application for amounts originating under the Agreement; and (vi) agrees to maintain a sufficient balance in the authorized bank account to cover all liabilities incurred under the Agreement.
American Express: By signing below, I represent that I have read and am authorized to sign and submit this application for Merchant, which agrees to be bound by the American Express® Card
Acceptance Agreement (“CAA”), and that all information provided herein is true, complete and accurate. I authorize Clearent and American Express Travel Related Services Company, Inc. (“American Express”) and American Express’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 agents, subcontractors, Affiliates, and other parties for any purpose permitted by law. I authorize and direct Clearent and American Express and American Express’s agents and Affiliates to inform me directly, or inform Merchant, 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 American Express 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 American Express’s approval of the application, Merchant will be provided with the CAA and materials welcoming it to American Express’s Card acceptance program.
The Agreement constitutes the entire agreement between the parties with respect to the subject matter and supersedes any prior agreements and understandings between the parties.
IN WITNESS WHEREOF, the parties have caused the Agreement to be executed by their duly authorized officers:
Title not applicable to
guarantor - leave empty
Title not applicable to
guarantor - leave empty
Principal Authorized Signer:
Name Printed:
Title:
Date:
Name Printed:
Title:
Date:
Guarantor Authorized Signer:
Name Printed:
Date:
Clearent Signature:
Name Printed:
Title:
Date:
Bank Signature:
Name Printed:
Title:
Date:
Merchant Acceptance of Application & Agreement
Date:
Guarantor Authorized Signer:
Name Printed:
Personal Guaranty. In consideration of 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 Bank and Clearent under the Agreement, and payment of all sums due thereunder. This is a continuing guaranty and Guarantor agrees that it shall remain in full force and effect until the Agreement is terminated and any associated indebtedness by Merchant is paid in full. Notice of default by Merchant is hereby expressly waived, and it is expressly stipulated that no delay or omission on the part of Bank or Clearent in enforcing the collection of their claims or demands against Merchant shall be held to in any way impair or affect the liability of Guarantor hereunder. Guarantor waives any and all defenses based on suretyship or impairment of collateral. Guarantor agrees to pay all costs and expenses of whatever nature, including attorneys’ fees and other legal expenses, incurred by or on behalf of Bank or Clearent in connection with the enforcement of this Guaranty. This guaranty shall bind and inure to the benefit of the personal representatives, heirs, administrators, successors and assigns of Guarantor, Bank and Clearent.
222 S. Central Ave, Suite 700, Clayton, MO 63105 | TEL 314 732 0515 | FAX 314 721 7300 | www.clearent.com
Clearent LLC is a registered ISO/MSP of Central Bank of St. Louis | 7707 Forsyth Blvd, Clayton, MO 63105 | TEL 314 746 4642
v20141115
Page 3 of 5
0.15
0.15
0.95
0.95
0.05
0.05
25.00
15.00
0.00
0.00
✔
0.05
0.00
0
✔0
0
5.00
2.50
25.00
5.00
0.00
✔ ✔ ✔ ✔Name (as shown on your income tax return)
Business name/disregarded entity name, if differs from above (Doing Business As (DBA) name)
Signature of
U.S. person:
Under penalties of perjury, I certify that:
1.
The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be
issued to me), and
2.
I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been
notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to
report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding,
and
3.
I am a U.S. citizen or other U.S. person (defined below).
Certification instructions: You must cross out item 2 above if you have been notified by the IRS that you are currently
subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate
transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property,
cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than
interest and dividends, you are not required to sign the certification, but you must provide your correct TIN.
Social security number
Enter your TIN in the appropriate box. The TIN provided must match the name
given on the “Name” line to avoid backup withholding. For individuals, this is your
social security number (SSN). For other entities, it is your employer identification
number (EIN).
Note: Please see detailed instructions at
http://www.irs.gov/pub/irs-pdf/fw9.pdf
.
To comply with Internal Revenue Service (IRS) and card association reporting requirements, we must know the
legal name of your business and its Taxpayer Identification Number (TIN). Please complete the W-9 below,
making sure it matches your EIN letter (IRS notification CP 575 A), a copy of your W-9, and/or your tax return.
To see complete instructions for the W-9, go to
http://www.irs.gov/pub/irs-pdf/fw9.pdf
.
Part I
Part II
Certification
Taxpayer Identification Number (TIN)
Employer identification number
Sign
Here
Date:
(Rev. December 2011) Department of the Treasury Internal Revenue Service
