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Home My WebLink About5.678 Original Contract Date Merchant Application D Re-Enrollment 5. &J18 Legal or Corporate Name of Bus mess CITY OF PORT ANGELES Federal Tax 10 Year Estabhshed D/B/A Name of Busmess CITY OF PORT ANGELES PERMITS Contact Name REBECCA HORTON Mad Statements D/B/A Busmess Address 321 EAST 5TH STREET CIty PORT ANGELES Slate Busme>> Telephone 360-417-4602 Store # Customer Service Telephone 360-417-4602 Busmess Fax Webslte Address Q 98362 360-417-4609 Country WASHINGTON , N '+ ,~ '} REBECCA HORTON 321 EAST 5TH STREET PORT ANGELES %'1", ' ", ' D Sole ProprIetor DGeneral Partnership PO BOX 1150 Slate WASHINGTON Zip Code 98362 Corporate Telephone 360-417-4602 Corporate Fax 360-417-4609 Country USA ,)~ j 4~ '"' ~,% 0:,\# Dc Corpora"on - Pnvate Co D Sub S Corp DLImtted LIabthty Corp DTax Exempt (mcluded Fed Tax Id and documents to support Exempt Status) [RIGovt (LocaVState!Federal) DOlher (Trusts, ete) FINANCE DIRECTOR FIrst Name YVONNE Home Address Emad Address vZlomkowskl@Cllvofoa US Officer (lttle) Home Address [mati Address City State Zip Code SSN DYes [RI No DYes ~NO Dyes [RI No Home Telephone DrIver's License ID # State hsued DaB Have YOll or any of the OWllerslPartnen./Oflil.,ers ufthe company ever filed bankruptcy for busmellos or personal bankruptcy? If yes, ple~e explam Years experience m thiS mdustry Years Months Has thiS DBA account ever accepted credit or debit cards preVIOusly? (under current ownership) Jfyes, name of the prevIous card acceptance processor Ifno and you have been m busmess more than 3 months, please explam why you have never accepted credit cards Have your or any of the OwnersJPartnersJOfficers of the comp.my ever been termmated or suspended by any card acceptance company? If yes, please explam Do you operate seasonally? DYes [RI No June D July D Aug D Sept D Oct D Nov D Dee If more than 20% of sales accepted by a retail merchant are via Mall, Telephone or Internet, please compelete a separate apphcatlon package(s) for the MOrrO and/or Internet sales Card Present (&wlped) % Card Present (not SWiped) % Mati Order % Telephone Order % Internet 100 % (totals must equal 100%) DeSCription of pro ducts or services offered GOVERNMENT SERVICES- PERMITS 5,000,000.00 TOIaI Monthly VISAlMC Sales $ 5,000.00 Average Sale Amount $ 50.00 Total Monthly Sales of Bus mess $ For Card Present transactions, when does the customer receive lhe product or lloervlce? For Mallffclcphone or Internet Transations Dsame Day DUnol same day, # of Days (mclude shlppmg tlmeframe) When does the customer receive the product or service? # of Days (mdude shlppmg tlmeframe) DYes [RINo If yes, please provide name afcompany, address and telephone Do you Woe a fulfillment hOWoe or telemarketmg company? For Internet Transactions: Product Wehslle Address N/A Doe& the webllolte meet all mternet requirements? DYes DNo Is thiS webstte secure? DYes DNo TERMS OF SERVICE VERSION # Page 1 00 GENAPPt03t031E Please Initial Here Merchant Application ~ " " # ' ; q " ,"'~ ~ ij ^ " Deposlt Bank Name US BANK I ABAlRoutmg # 125 000 105 DDA Account # 1 535 0212 0816 BIlhng Bank Name (If dtfferent) I ABAlRoutmg # DDA Account # Pricing Category' D RetalVRestaurant D Lodgmg D MOrrO ~ Internet D Emergmg Market D Supennarkct D Auto Rental D Pay at Pump DARU D Paper , fJy;;{fiFJJAT(~' , <_iI" , " h , " '}mt x * Card Acceptance: (please check each card you wish to accept) ~ All VISA/MasterCards 0 VISA Credit OMasterCard Credit DVISA Debit 0 MasterCard Debit Note acceptance of card fltpes not selected will result En dIScount downvades D TIERED Qualified Rate MldlPartlal Qualified Rate Non-Qualified Rate Rate Per Hem Rate Per Item Rate Per Item VISA Credll/Deblt N/A N/A N/A N/A N/A N/A MasterCard CreditIDebit N/A N/A N/A N/A N/A N/A ~ INTERCHANGE DIFFERENTIAL D INTERCHANGE AND ASSESSMENTS PLUS Ix3l Rate n Discount Per Item VISA Credit 1.67% $0.10 VISA Debit 1.04% $0.30 MasterCard Credit 1.79% $0.10 MasterCard Debit 1.26% $0.10 f!!J,$~ ^ 't ""~ ~ ~~. '" . "...&:; ,.~ , S:' $ Fee Tvpe Amount Freanencv Card/Prodpct Tvpe Amopnt Freauencv ApplicatIon Fee $195.00 Non-refundable VISA Per Authorization Account MalOtenance Per Occurrence MasterCard Per AuthonzatlOn ARU Auth Capture Per Occurrence AMEX- $0.15 Per Authonzahon Batch Settlement Per Occurrence DSCV-60110 $0.15 Per Authortzatton Debtt Setup One Time Fee EBT- $0.15 Per Authortzatton Statement Fee $5.00 Per Month DNCB- $0.15 Per AuthonzatlOn Equtpment Swap Year I N/A Per Occurrence lCB- $0.15 Per Authortzalton EqUIpment Swap Year 2 + N/A Per Occurrence Regtonal Debtt N/A Per Authonzahon InstallatIOn I Trammg One Time Fee Nattonal DebIt N/A Per AuthonzatlOn Internet Per Month Foretgn Network N/A Per Authonzahon Charge-back Fee $15.00 Per Occurrence VOIce Auth (Touch Tone) $0.65 Per Authortzalton Membershtp Fee One Time Fee VOIce Auth Operator ASSISted $0.90 Per AuthonzatIon MInimum Dlscount $25.00 Per Month VOIce wtth A VS $0.90 Per Authonzaltan Other Votce Bank Referral $4.00 Per Authortzalton Other Overall Termmal Auth Fee (All Cards) Per Authonzalton Reprogrammmg Fee N/A One TIme Fee ~ ~ , ;~ ~ l, , , " ~ Return Item Fee $20.00 Per Occurrence D American Express 10I1Ial Acceptance of Amex Fees and Terms - Rush Shtpment One Ttme Fee Amex % Rate Amex Flat Fee Optlon Stte Survey One Ttme Fee Average Ticket Montbly Volume Suppltes Direct Bill Per Occurrence Franchise Name Franchise Cap ARC Gross Pay DDally d=? Monthly 95 Dally (i'lJ ' > :&~ftPI;%.fi { Pay Frequency (# days delay) 3 0 15 30 D Electronic Check D GIft Card (EGC) D ARS (Care) D DIScover EASI: Initial Acceptance of Discover Fees and Terms - D Scan Check Service - Venficatlon Only Membership fee Discover % Per Item Set Up Fee Discover pcr Item Fee Franchise Code Discover Outlet D Smgle D Outlet reportmg to Headquarters D Headquarters r:{XUm~$(;!I;g t , ,<)~ /~:hs",,<;:, ", P'iX~ :;~~tYjn~~1t<~' <;'~y\~'~%'~~:w~ _Z:~; ~*tllllliBli11ipd(<<'4R~,JJslL. JJiKiJi:f:i,0- EI/uioment / Product Item Setup Monthly Per Item Qty Merchant Lease * Rental" Exchange" Purchase NIU Pnce Total Amount Due Descriotion Code Fee Fee Fee Owns (Purchase Only) VAR VAR 1 ~ D 0 0 D $0.00 $0.00 D D D D D D D D D D D D D 0 D . Attach Lease I Rental Agreement If apphcable .. Exchange EqUipment to be picked up $ Total Due (excludmg appltcable sales tax) $0.00 Page 2 of3 GENAPP2031031E Please Imtlal Here Merchant Application Merchant Reoresentations and Certifications. By slgnmg below, the apphcant merchant ("Merchant") and Its representahve(s) represent and warrant to NOVA Information Systems, Ine ("NOVA"), WIth offices at 7300 Cbapman Hlgbway, Knoxville, TN 37920, and U S Bank, N A ("Member"), wltb offices at U S Bankcorp Center, gOO Nlcolle~ Mmncapolos, MN, 55402 (collectIvely, "we" or "us") that (I) all mformatlOn provided In this merchant apphcatton ("ApplicatIOn") IS true, complete and accurate and properly reflects the busmess, financial condition, and pnnclpal partners, owners, or officers of Merchant, and (II) the persons slgmng thiS ApphcatJon have the power to execute and are duly authorIzed to bmd Merchant to all provIsions of thiS ApplicatIon and the Terms arServlce (the "TOS") Merchant, by Its signature on the Application, Of upon Its first transmiSSion of Sales Drafts. acknowledges that It has received, understands and agrees to be bound by the TOS and the ApphcatIon Merchant agrees that Its first transmiSSion of Sales Drafts to NOVA and/or Member constitutes Merchant's acceptance of the TOS Merchant agrees to comply With the Apphcatlon, TOS, and all applicable laws, rules, and regulations ancludmg the rules and regulations of the Credit Card AsSOCiations and EFT Networks, and understands that failure to comply wIll result m termanatlOn of processmg services Capitalized terms shall, unless otherwise defined m thiS ApplIcation, have the same meanIng asCribed to them In the TOS Merchant agrees to establish and mamtam suffiCient funds In an account to accommodate all transactIOns mcludmg, but not limited to, fees, fines and chargebacks Merchant authorizes us to credit/debit that account as necessary Merchant understands that we may take any of the followmg actions If necessary to protect ourselves from finanCial loss estabhsh, or reqUire Merchant to establish, a reserve account, Impose a processmg hmlt or cap on the dollar amount of sales transactions that we Will process for Merchant, which may be changed from time to time With or Without notice to Merchant, and/or suspend the processmg of sales drafts for as long as necessary to mvestIgate SUSpICIOUS, unusual or excessive deposit activity Merchant Will oblam a pnor authorIzation via electromc temunal or similar deVice before completmg any transactIon Merchant understands that AUTHORlZA nONS ARE NOT A GUARANTEE OF ACCEPTANCE OR PAYMENT OF A TRANSACTION RECEIPT OF AN AUTHORlZA TlON DOES NOT MEAN THAT MERCHANT WILL NOT RECEIVE A CHARGEBACK FOR THAT CARD TRANSACTION If Merchant term mates wlthm one year of the date set forth below, Merchant wllllmmedtately pay NOY A, as liqUidated damages, an early termmatlon fee equal to $295, m addition to all other amounts owed If Merchant term mates at any time durmg the second or third year of the date set forth below, the Merchant Will pay, as liquidated damages, a termmatlon fee equal to $195, In addition to all other amounts owed Merchant agrees that the early termination fee IS not a penalty, but rather IS reasonable In light of the financJaI harm caused by Merchant's early termination NOY A Will use best efforts to debit the Merchant's account m the amount of the applicable termination fee wlthm SIXty (60) days of receipt of Merchant's written notice of termination Merchant and its representatlve(s) authOrize us pnor to our acceptance of thiS ApphcatlOn and from time to time thereafter, to mvestlgate the mdlvldual and busmess history and background of Merchant, each such representative and any other officers, partners, propnetors, and/or owners of Merchant, and to obtam credit reports or other background mvestlgatIon reports on each of them that we consider necessary to review the acceptance and contmuatlOn of this ApplIcatIOn Merchant also authonzes any person or credit reportmg agency to compile mformatlon to answer those credit mqulres and to furnish that mformatlon to us IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING A NEW ACCOUNT To help the government figbt the fundmg ofterronsm and money laundenng actIVIties, Federal law reqUires all finanCial Instutlons to obtaan, venfy, and record mformatlon that Identifies each person who opens an account ThiS means that when openmg thiS account, we Will ask for name, address, date of birth and other Idenhfymg mformation We may also ask to see Identlfymg documents, such as a dnver's license or passport Merchant further acknowledges and agrees that any mfonnatlOn provided 10 connection with thiS Application and all other relevant mformatlon may be supphed by us to our affihates ThiS ApplIcation may be signed 10 one or more counterparts, each of which shall constItute an ongInal and all of which, taken together, shall constitute one and the same ApplIcation Delivery of executed counterparts of thiS ApplIcation may be effected by a faCSimIle transmisSion, and a signed faCSimile or copy of this Application shall constitute a signed onglnal , '0/11 /C00SIc/ Date I Signature Prmted Name & Title Date 17 /f/tlVce f)}~ {/7jOfj Personal Guarantv. As a pnmary mducement to us to accept thiS ApplIcauon, the undersigned Guarantor(s), by slgnmg the ApphcalIon, Jomtly and severally, uncondllIonally and mevocably, guarantee the continuing full and faithful perfonnance and payment by Merchant of each of Its duties and obligatIOns to us (mcludIng, WithOUt limitatiOn, chargebacks) pursuant to the ApplIcatIOn and TOS, as may be amended from time to time, With or WithOUt notIce Guarantor(s) understands further that we may proceed directly agamst Guarantor(s) WithOUt first exhaustmg our remedies agamst any other person or entity responsible therefore to them or any secunty held by us or Merchant ThiS guarantee Will not be discharged or affected by the death of the Guarantor(s), Will bmd all heirS, admmlstrators, representatives and assigns and may be enforced by or for the benefit of any of our successors Guarantor(s) understands that the mducement to us to accept thiS ApplicatIon IS consideratIon for the guaranty and that thiS guaranty remams 10 full force and effect even If the Guarantor(s) receives no additIonal benefit from the guaranty Signature Prmted Name SSN# Date Signature Pnnted Name SSN# Date Coroorate Resolution: I certify that I hold the office mdlcated below of Merchant and am the keeper of the records of that company, orgamzed and eXlstmg under the laws of the state mdlcated below and that the followmg 1S a correct copy ofcertam resolutions adopted at a meetIng of the board of directors/general partnership/manager or members ofa limited liabilIty company, as appropnate, In accordance With the by-laws or other governmg document of the company held On the day of JUNE (month), 2004 (year) I Resolved, that anyone of the followmg officers of the company ~mVIN N 6 XI r{)/J7 kott98k/Slg~i/ ~-~ &: T,tle ~-4"7 r/)//fA/('/-;- /J112 . IS authOrized to A) execute on behalf of this company an Appllcauon and any agreements or other necessary documents mcludmg any amendments, B) execute any document requested from tIme to time be executed In furtherance of the ApplicatIon or relationship resulting therefrom, C) perform all acts that may be necessary to carry out the mtent of the ApplIcatIOn and these Resolutions 2 Resolved, that the Apphcal10n and the resultmg relatIOnship IS ratified and approved, 3 Resolved, that the entities recelvmg thiS Apphcatlon are authOrized to rely upon thiS Corporate Resolution until adVised m WrItIng by a lIke certification of any changes and are authonzed to rely on such changed certification y Submitted Bv: To the best of my knowledge, I certify that the mformatlon prOVided 10 thiS Merchant ApplIcation was proVided by the Merchant and IS true, complete and accurate I further certify that the signatures were prOVided by the Merchant's owner(s) or officer(s), as appropnate Sales Representative Signature Pnnted Name Rep ID # Date FOR OFFICE USE ONLY: Accepted by NOY A Information Systems, loc Page 3 of3 Accepted by Member USBMP A03 103 I E