Apply Now 1 Merchant Information 2 Principals 3 Corporate Informaton 4 MO/TO Questionnaire (IF APPLIES) 5 Bank Account Information Merchant InformationMerchant Name (DBA or Trade Name)Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Corporate InformationIs the Merchant Name & Address the same as the corporate?Choose value from dropdown...YesNoCorporate / Legal NameAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code More InformationContact NameContact Email Address Contact Phone NumberFax NumberFederal Tax ID #Does this location currently accept payment cards?Choose value from dropdown...YesNoPlease provide reason for leaving current processor.Has merchant or owners/principals ever been terminated from accepting payment cards from any payment network for this business or any other businesses?Choose value from dropdown...YesNoPlease explain reason for termination. PrincipalsName First Last SSN% OwnershipTitleAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date Of BirthEmail Address Phone NumberDrivers License #Drivers License StateChoose value from dropdown...AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificIs there another Principal?Choose value from dropdown...NoYesName First Last SSN% OwnershipTitleAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date Of BirthEmail Address Phone NumberDrivers License #Drivers License StateChoose value from dropdown...AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Type Of BusinessChoose value from dropdown...Individual / Sole ProprietorPartnershipCorporationLLCNon-ProfitPrivatePublicly TradedGovernmentLength of time in business:YearsMonthsNature Of BusinessChoose value from dropdown...RetailRetail w/TipsMail / Phone OrderInternetRestaurantFast FoodLodgingQSRConveniencePublic ServicePetroleumUtilityHealth Care MerchantOtherPlease specify Nature of Business.Seasonal Sales?Choose value from dropdown...YesNoSelect High Volume MonthsJanuaryFebruaryMarchAprilMayJuneJulyAugustSepetemberOctoberNovemberDecemberMethod Of AcceptanceCredit Cards Swiped %Please enter a value less than or equal to 100.Key Entered %Please enter a value less than or equal to 100.Internet %Please enter a value less than or equal to 100.MO/TO %Please enter a value less than or equal to 100.Total Combined %TOTAL MUST EQUAL 100%VolumesMonthly Payment Card Volume ($)American Express Volume ($)Average Ticket ($)High Ticket ($)Merchant VolumeChoose value from dropdown...Retail Merchant Volume < $500,000 / MonthCard Not Present Merchant Volume < $99,000 / MonthCard Not Present Merchant Volume < $100,000 - $500,000 / MonthMerchant Volume $500,000+ / MonthCONTINUING PERSONAL GUARANTY PROVISION (“GUARANTY”) – PERSONAL GUARANTOR (Capitalized terms not defined in this Guaranty have the meanings set forth below in the Terms and Conditions) By signing below, each individual or entity (“Guarantor”) jointly and severally (if there is more than one Guarantor) and unconditionally guarantees to ISO and Bank the prompt payment and full and complete performance of all obligations of Merchant identified above under the Agreement, as amended from time to time, including, without limitation, all promises and covenants of the Merchant, and all amounts payable by Merchant under the Agreement, including, without limitation, charges, interest, costs and other expenses, such as attorneys’ fees and court costs. This Guaranty means, among other things, that ISO or Bank can demand performance or payment from any Guarantor if Merchant fails to perform any obligation or pay any amount Merchant owes under the Agreement. Each Guarantor agrees that his or her liability under this Guaranty will not be limited or canceled because: (1) the Agreement cannot be enforced against Merchant for any reason, including, without limitation, the initiation of bankruptcy proceedings; (2) either ISO or Bank agrees to changes or modifications to the Agreement, with or without notice to Guarantor; (3) ISO or Bank releases any other Guarantor or Merchant from any obligation under the Guaranty or Agreement, as applicable; (4) any Law affects the rights of either ISO, Merchant, or Bank under the Agreement; and/or (5) anything else happens that may affect the rights of either ISO or Bank against Merchant or any other Guarantor. Each Guarantor further agrees that: (a) ISO and Bank each may delay enforcing any of their rights under this Guaranty without losing such rights; (b) ISO and Bank each can demand payment from such Guarantor without first seeking payment from Merchant or any other Guarantor or from any security held by Bank; and (c) such Guarantor will pay all court costs, attorneys’ fees, and collection costs incurred by either ISO or Bank in connection with the enforcement of the Agreement or this Guaranty, whether or not there is a lawsuit, and such additional fees and costs as may be directed by a court. If Merchant is a corporation, limited liability company, partnership or other entity, this Guaranty must be executed by a principal of Merchant. Applicant SignatureApplicant Name First Last Date Principal Name First Last Date Upload most recent month's processing statement (if applicable)Upload copy of a voided check or bank letter on bank letterhead (no temporary checks)Merchant Volume < $99,000 / MonthUpload 3 most recent months' previous processing statements (if applicable) Drop files here or Upload 1 month's recent bank statement.Upload copy of a voided check or bank letter on bank letterhead (no temporary checks)Upload sample of marketing piece (live URL for e-commerce)Merchant Volume < $100,000 - $500,000 / MonthUpload 3 most recent months' processing statements. Drop files here or Upload 1 month's recent bank statement.Upload copy of a voided check or bank letter on bank letterhead (no temporary checks)YTD Profit & Loss and Balance Sheet1 Year of business tax returns (personal tax returns if unavailable)Merchant Volume $500,000 + / MonthContact 678.496.3083 or sales@calpiancommerce.comProduct / Service InformationProduct or Service being offered:Does the merchant use Software or Terminal?Choose value from dropdown...SoftwareTerminalWhat is the Payment Application Name?What is the version of the Payment Application?What type?Merchant Name to appear on consumer statement:Choose value from dropdown...DBA NameLegal NameOtherExplainOther Merchant InformationDoes Merchant Use An Independent Servicer That Stores, Maintains Or Transmits Cardholder Information?Choose value from dropdown...NoYesNamePhoneDoes Merchant Use A Fulfillment House To Fulfill Product?Choose value from dropdown...NoYesNamePhoneHave Merchant Or Owners / Principals Ever Filed Business Bankruptcy and/or Personal Bankruptcy?Choose value from dropdown...NoYesExplanation MO/TO QuestionnaireWhat percentage of sales are to:Businesses Consumers ( % )Individual Consumers ( % )Method Of MarketingChoose value from dropdown...Newspaper / MagazineTelevision / RadioInternetDirect Mail, Brochure and/or CatalogOutbound Telemarketing SalesOtherExplainPercentage of products sold via:Telephone Orders ( % )Mail / Fax Orders ( % )Internet Orders ( % )Other Orders ( % )Who processes the order?Choose value from dropdown...MerchantFulfillment CenterOtherExplainWho enters credit card information into the processing system?Choose value from dropdown...MerchantFulfillment CenterConsumerOtherExplainIf credit card payment information is taken over the Internet, is payment channel encrypted by SSL or better?Choose value from dropdown...NoYesIf Merchant is an e-commerce Merchant, is a Merchant Certificate utilized?Choose value from dropdown...NoYesMerchant Certificate NumberCertificate IssuerExp. DateCertificate TypeChoose value from dropdown...IndividualSharedDo you own product / Inventory?Choose value from dropdown...YesNoIs product stored at your business location?Choose value from dropdown...YesNoWhere is it stored?After charge authorization, how long until product ships? ( Days )Who ships the product?Choose value from dropdown...MerchantFulfillment CenterProduct Shipped By:Choose value from dropdown...US MailOtherExplainDelivery Receipt Requested?Choose value from dropdown...YesNo Bank Account InformationType Of AccountChoose value from dropdown...Checking AccountSavings AccountBank NameTransit # (ABA Routing)Account # (DDA)ContactPhone NumberPlease Scan & Upload voided check for the Account where funds are to be deposited.* By providing the above referenced information, you are authorizing Bank to initiate ACH debit and credit transactions to said account.Trade ReferencesReference 1Name First Last PhoneReference 2Name First Last PhoneSite InspectionMerchantChoose value from dropdown...OwnsRentsLandlordBuilding TypeChoose value from dropdown...Shopping CenterOffice BuildingIndustrial BuildingResidenceArea ZonedChoose value from dropdown...CommercialIndustrialResidentialSquare FootageChoose value from dropdown...0 - 500501 - 25002501 - 50005001 - 10000+New Account AgreementIMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING A NEW ACCOUNT To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. What this means for you: When you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver’s license or other identifying documents. MERCHANT APPLICATION AND AGREEMENT ACCEPTANCE Capitalized terms not defined in this Acceptance Section have the meanings set forth below in the Terms and Condition) By executing this Merchant Application (“Merchant Application”), on behalf of the merchant described above (“Merchant”), the undersigned authorized individual(s) each, jointly and severally, represents, warrants, acknowledges and agrees that: (i) all information supplied by Merchant to ISO and Merrick Bank Corporation (“Bank”) and contained in this Merchant Application is true, correct and complete as of the date of this Merchant Application; (ii) if Merchant is a corporation, limited liability company, or partnership, the individual(s) executing this Merchant Application have the requisite legal power and authority to complete and submit this Merchant Application on behalf of Merchant and to make and provide the acknowledgements, authorizations and agreements set forth herein on behalf of Merchant and individually and to bind Merchant to the terms of this Merchant Application, the Guaranty and the attached Terms and Conditions, as may be amended from time to time (collectively, the “Agreement”); (iii) the information contained in this Merchant Application is provided for the purpose of obtaining, or maintaining, a merchant account for Merchant with the Bank and Bank and ISO will rely on the information provided herein in its approval process and in setting the applicable discount rate, approved average ticket, and approved monthly Card volume; (iv) Bank is authorized to investigate, either through its own agents or through credit bureaus/agencies, the credit of Merchant and each person listed on this Merchant Application; (v) Bank will determine all rates, fees and charges and notify Merchant of the approved fees and by Merchant's submission and acceptance of Merchant's first settled transaction, Merchant agrees to pay such fees in accordance with the terms of the Agreement; (vi) the Agreement will not take effect until Merchant has been approved by Bank and a merchant identification number has been issued to Merchant; and (vii) Merchant and the undersigned have received, read and understood the Agreement, and Merchant agrees to be bound by the terms of the Agreement. Merchant acknowledges that this Agreement is being submitted to Bank, as the member bank of the Card Networks, and ISO is also a party to this Agreement. Merchant acknowledges that ISO will rely on the representations and warranties set forth in this Agreement and unless otherwise specified or prohibited by the Network Rules or Law, ISO will have certain rights under this Merchant Application and Agreement.Applicant SignatureApplicant Name First Last Date Principal 2 Name First Last Date Opt Out By checking the box, Merchant opts out of receiving future commercial marketing communications from American Express.