Merchant Application and Fee Schedule

SECTION 1 – MERCHANT BUSINESS INFORMATION

MEMBER BANK: Fifth Third Bank, N.A. (c/o Worldpay LLC, 8500 Governors Hill Drive, Symmes Township, OH 45249)

Business Legal Name (must match tax return)

Business Name (DBA)

Contact Name

Check here if Corporate Headquarters

Business Location Address

City

State

Zip

Business Billing Address

City

State

Zip

Phone

Fax

Website

Email address

Federal Tax ID

Is Merchant a government entity or at least 50% owned/controlled by a government entity?

If yes, list country name

Control Owner / Officer / Principal

Name

Title

Home Address

Phone

City

State

Zip

SSN

DOB

% Ownership

SECTION 2 – BENEFICIAL/CONTROL OWNERSHIP INFORMATION

To help the government fight financial crime, federal regulation requires disclosure of beneficial owners.

Beneficial Owner #1

Name

Title

Home Address

Phone

City

State

Zip

SSN

DOB

% Ownership

Beneficial Owner #2

Name

Title

Home Address

Phone

City

State

Zip

SSN

DOB

% Ownership

Beneficial Owner #3

Name

Title

Home Address

Phone

City

State

Zip

SSN

DOB

% Ownership

Beneficial Owner #4

Name

Title

Home Address

Phone

City

State

Zip

SSN

DOB

% Ownership

SECTION 3 – IMPORTANT DISCLOSURES

IMPORTANT DISCLOSURES: Please review carefully. By continuing, Merchant acknowledges having read and understood the disclosures provided by Worldpay/NPC and Fifth Third Bank, N.A.

I acknowledge receipt and review of the Important Disclosures.

SECTION 4 – BUSINESS PROFILE AND ASSUMPTIONS

Provide your business processing profile and assumptions.

Date Business Opened

Existing MID (if any)

Merchant Category Code (MCC)

Type of Goods/Services

Annual Volume (USD)

Average Ticket

Highest Ticket

Refund Policy

SECTION 5 – COMPLIANCE INFORMATION

PCI/PA-DSS Compliance and Data Security.

Has the Merchant ever experienced a data compromise?

Third Party Gateway Provider

Third Party Contact

SECTION 6 – MERCHANT BANK ACCOUNT INFORMATION

Bank account information for deposits and fees.

Primary Routing Number

Primary Account Number

Secondary Routing Number

Secondary Account Number

SECTION 7 – FEE SCHEDULE

Merchant Discount and Fee Schedule

Application Type

Discount Frequency

Card Options

Chargeback Fee (USD)

PCI Basic Fee (USD)

SECTION 8 – OCCURRENCE FEES

Occurrence Fees (per event)

Retrieval Fee

Batch Fee

SECTION 9 – UNLIMITED PERSONAL GUARANTY

Unlimited Personal Guaranty

Guarantor Name

Guarantor Phone

Home Address

Zip

SECTION 10 – PATRIOT ACT AND BACKGROUND AUTHORIZATION

Patriot Act & Background Authorization

Authorized Person Name

Taxpayer ID

Physical Address

Date of Birth

SECTION 11 – MERCHANT ACKNOWLEDGEMENTS AND SIGNATURE

Merchant agrees to and accepts the terms and conditions set forth in this Application and the Terms and Conditions (GEN.0123) as if fully set forth herein (collectively, the “Merchant Agreement”).

Merchant Name (Printed)

Date of Signature

Merchant Signature

Guarantor Signature

SECTION 12 – EQUIPMENT SETUP

Equipment Setup

Equipment (JSON)

Fulfillment House Name

SECTION 13 – SITE INSPECTION INFORMATION

Site Inspection

Merchant location physically inspected

No physical inspection, but business verified

Third party site inspection pending

Comments

MERCHANT PROCESSING AGREEMENT

Enter your Client Code

SECTION 1 – MERCHANT BUSINESS INFORMATION

Control Owner / Officer / Principal

SECTION 2 – BENEFICIAL/CONTROL OWNERSHIP INFORMATION

SECTION 3 – IMPORTANT DISCLOSURES

SECTION 4 – BUSINESS PROFILE AND ASSUMPTIONS

SECTION 5 – COMPLIANCE INFORMATION

SECTION 6 – MERCHANT BANK ACCOUNT INFORMATION

SECTION 7 – FEE SCHEDULE

SECTION 8 – OCCURRENCE FEES

SECTION 9 – UNLIMITED PERSONAL GUARANTY

SECTION 10 – PATRIOT ACT AND BACKGROUND AUTHORIZATION

SECTION 11 – MERCHANT ACKNOWLEDGEMENTS AND SIGNATURE

SECTION 12 – EQUIPMENT SETUP

SECTION 13 – SITE INSPECTION INFORMATION