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New Merchant Application Form

Cover Sheet
Business (DBA)*
Contact Name*
First Last
Business Address*
Street Address Address Line 2 City State ZIP Code
Business Phone Number*
Merchant Information
DBA Name*
Legal/Corporate Name*
Contact Name*
First Last
DBA Address*
Street Address Address Line 2 City State ZIP Code
Email Address*
DBA Phone Number*
DBA Fax Number
Year Established*
Length of Current Ownership*
*
Mobile Phone*
Mailing Address
(If different than above)
Type of Address
(can select more than one)
- Mailing
- Shipping
DBA Name
Contact Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone Number
Principal 1 Information
(Owner/Partner/Officer)
Role*
Percentage of Ownership*
Title*
Name*
First Last
Home Address*
Street Address Address Line 2 City State ZIP Code
SSN#*
DOB*
Home Phone*
Other Merchant Information
Average Sale Amount*
Total MONTHLY Visa/MC/Disc/UnionPay/Amex Sales*
Description of Product/Services Offered*
What percentage of your sales are...
Card Present*
Please enter a number from 0 to 100.
Card Not Present*
Please enter a number from 20 to 100.
Internet*
Please enter a number from 0 to 100.
(Must total 100%)
Customer Service Number
Previous Processor
Bank Account
(Checking Accounts Only)
Deposit Bank Name*
ABA/Routing #*
DDA Account #*
Tape ID
Card Acceptance
Pricing Category*
Pricing Information
Are you applying with a sales rep?*
Sales Rep Name
First Last
Pricing Type
Visa/Mastercard/Discover/UnionPay
Qualified
Rate (%) Per Item ($)
Mid Qualified
Rate (%) Per Item ($)
Non Qualified
Rate (%) Per Item ($)
American Express
Qualified
Rate (%) Per Item ($)
Mid Qualified
Rate (%) Per Item ($)
Non Qualified
Rate (%) Per Item ($)
Markup: Visa/Mastercard/Discover/UnionPay
Rate (%) Per Item ($)
Markup: American Express
Rate (%) Per Item ($)
Fees:
- Account Maintenance: $20.00
- Chargeback (per occur): $25.00
- Return Item Fee/NSF (per occur): $25.00
- Annual Fee: $99.00
- Monthly Service Fee: $6.00
- Monthly Minimum: $35.00
- Monthly Association Compliance Fee: $6.00
Authorizations (per occurrence)
- Dial Communication: $0.03
- Voice Auth Touch Tone: $0.65
- Voice - Operator Assisted: $0.95
- Voice - with AVS: $1.95
- Voice - Bank Referral: $2.65
Point of Sale Equipment
Quantity Price Per Unit ($) Monthly Fee ($) Per Auth ($)
Type
Additional Equipment
Quantity Price Per Unit ($) Monthly Fee ($) Per Auth ($)
Type
Additional Equipment
Quantity Price Per Unit ($) Monthly Fee ($) Per Auth ($)
Type
Substitute Form W-9
Business Type*
Tax Classification*
Name*
Name (of business) as shown on your business income tax returns. For Sole Proprietors, this should always be the owner's name.
Address*
Street Address Address Line 2 City State ZIP Code
TIN (Employer ID #)*
Merchant Representations and Certifications
Merchant Representations and Certifications. By signing below, the applicant merchant (“Merchant”) and its representative(s) represent and warrant to Elavon, Inc. (“Elavon” or “Member” as applicable), with offices at 7300 Chapman Highway, Knoxville, TN 37920
(collectively, “we” or “us”) that (i) all information provided in this merchant application (“Merchant Application”) is true and complete and properly reflects the business, financial condition, and principal partners, owners, or officers of Merchant; and (ii) the persons signing this Merchant Application are duly authorized to bind Merchant to all provisions of this Merchant Application and the Agreement. The signature by an authorized representative of Merchant on the Merchant Application, or the transmission of a Transaction Receipt or other evidence of a Transaction to us, shall be the Merchant’s acceptance of and agreement to the terms and conditions contained in the Agreement including, without limitation, this Merchant Application, the Terms of Service (“TOS”) and the Merchant Operating Guide (“MOG”) incorporated herein by this reference and located at our website at https://www.merchantconnect.com/CWRWeb/pdf/TOS_ENG.pdf and https://www.merchantconnect.com/CWRWeb/pdf/MOG_Eng.pdf, respectively. If Merchant does not have access to view the TOS or MOG at our website please contact our customer service center. Notwithstanding any such non-receipt of the TOS or MOG, Merchant agrees to comply with the Agreement, and all applicable laws, rules, and regulations including the rules and regulations of the Payment Networks, and understands that failure to comply will result in termination of processing services. Capitalized terms shall, unless otherwise defined in this Merchant Application, have the same meaning ascribed to them in the TOS and MOG.
IMPORTANT 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. This means we will ask for certain information and identifying documents to allow us to identify you. Merchant and its representative(s) authorize us prior to our acceptance of this Merchant Application and from time to time thereafter, to investigate the individual and business history and background of Merchant, each such representative and any other officers, partners, proprietors, and/or owners of Merchant, and to obtain credit reports or other background investigation reports on each of them that we consider necessary to review the acceptance and continuation of this Merchant Application. Merchant also authorizes any person or credit reporting agency to compile information to answer those credit inquiries and to furnish that information to us.
This Merchant Application may be signed in one or more counterparts, each of which shall constitute an original and all of which, taken together, shall constitute one and the same Merchant Application. Delivery of executed counterparts of this Merchant Application may be accomplished by a facsimile transmission, and a signed facsimile or copy of this Merchant Application shall constitute a signed original.
Merchant understands that an authorization code is not a guarantee of acceptance or payment of a Transaction. Receipt of an authorization code does not mean that merchant will not receive a Chargeback for that Transaction.
All merchants must comply with the requirements of the Payment Card Industry Data Security Standards (“PCI DSS”). Elavon requires Level 4 merchants (determined based on Transaction volume) to validate PCI DSS compliance on an annual basis, with initial validation to occur no later than ninety (90) days after account approval. Any merchant that has not validated PCI DSS compliance within ninety (90) days of account approval, or in subsequent years on or before the anniversary date of account approval, will be charged a monthly non-compliance fee of $30 until Elavon is provided with validation of compliance. Merchant may be eligible for Data Breach Coverage following account approval and PCI DSS compliance validation. See the PCI Compliance Program Overview for coverage details and conditions.
Under penalties of perjury, Merchant certifies that:
1. The number shown on this Merchant Application 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. For federal tax purposes, you are considered a U.S. person if you are: an individual who is a U.S. citizen, or U.S. resident alien, a partnership, corporation, company, or association created or organized in the United States or under the laws of the United States, an estate (other than a foreign estate), or a domestic trust (as defined in Regulations section 301.7701-7).*
American Express OptBlue Program. If Merchant has elected to accept American Express® Transactions (as indicated in Section 4 of this Merchant Application), in addition to all other terms of this Agreement, Merchant agrees to the provisions set forth in Section E (OptBlue Program) of the TOS. By signing below or by accepting a Transaction initiated with an American Express® Payment Device, Merchant expressly authorizes Elavon to submit American Express® Transactions to, and to receive settlement funds from, American Express on Merchant’s behalf. Merchant further authorizes Elavon to provide Merchant’s contact information to American Express, and Merchant agrees that American Express may use and share such contact information for its business purposes and as permitted by applicable Laws, including to communicate with Merchant regarding products, services, and resources available to Merchant’s business. American Express’s use of the email address and mobile phone number provided above is subject to the consent to such use as indicated in Section 1 of this Merchant Application. Consent to American Express’s use of contact information for such communications may be withdrawn at any time by contacting our customer service center. Even if consent is withdrawn, Merchant may still receive messages related to important information about Merchant’s account from American Express. Merchant or Elavon may terminate Merchant’s acceptance of American Express® Payment Devices at any time, with or without cause, without affecting Merchant’s rights and obligations pursuant to the remainder of this Agreement. Merchant acknowledges that, if at any time Merchant is no longer qualified to participate in the OptBlue Program, Merchant may be enrolled in the standard American Express® card acceptance program, which may have different terms and conditions than the OptBlue Program, and Merchant’s acceptance of American Express® Payment Devices pursuant to this Agreement will be terminated. Merchant acknowledges that American Express is an intended third-party beneficiary of this Agreement, solely with respect to the terms and conditions applicable to Merchant’s acceptance of American Express® Payment Devices, and that American Express has the right to enforce such terms and conditions directly against Merchant.
*
- I have read and agree to the terms and conditions.
Signature
Name*
First Last
Title*
Initials*
Date*
Date Format: MM slash DD slash YYYY
Personal Guaranty
As a primary inducement to us to accept this Merchant Application, the undersigned Guarantor(s), by signing the Merchant Application, jointly and severally, unconditionally and irrevocably, guarantee the continuing full and faithful performance and payment by Merchant of each of its duties and obligations to us (including, without limitation, Chargebacks and obligations in connection with Leased Equipment, if applicable) pursuant to the Merchant Application and Agreement, as may be amended from time to time, with or without notice. Guarantor(s) understand further that we may proceed directly against Guarantor(s) without first exhausting our remedies against any other person or entity responsible therefore to them or any security held by us or Merchant. This guarantee will not be discharged or affected by the death of the Guarantors, will bind all heirs, administrators, representatives and assigns and may be enforced by or for the benefit of any of our successors. Guarantor(s) understand that the inducement to us to accept this Merchant Application is consideration for the guaranty and that this guaranty remains in full force and effect even if the Guarantor(s) receive no additional benefit from the guaranty. The undersigned hereby directs any consumer reporting agency to furnish a consumer credit report that relates personally to the undersigned upon the request of Elavon or any of its designees, successors or assigns and agrees that all parties involved are in compliance with the Fair Credit Reporting Act.
Signature
Name*
First Last
Date*
Date Format: MM slash DD slash YYYY
Sales Use Only
Optional - for Agents
To the best of my knowledge, I certify that the information provided in 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 appropriate.
Sales Rep Signature
Sales Rep Name
First Last
Rep ID#
Date
Date Format: MM slash DD slash YYYY
Rep Phone #
Rep Email