Harbortouch POS Account Submission Checklist - United Bank Card

PROMO CODE:H A R B O R T O U C HAGENT NAMEOFFICE PHONE OFFICE CODEREP CODEASSOCOFFICE USEONLYNEW LOCATION OWNERSHIP CHANGE ADDITIONAL LOCATIONMERCHANT #SIC CODE FAIR ISAAC SCORE ANALYSTSECTION A — PLEASE COMPLETE MERCHANT'S BUSINESS INFORMATIONA1 MERCHANT INFORMATIONNAME OF ACCOUNT (DOING BUSINESS AS)EXACT LEGAL NAMEDBA ADDRESS (IF DIFFERENT FROM LEGAL)CITY COUNTYSTATE ZIPLEGAL ADDRESSCITY COUNTYSTATE ZIPCONTACTTELEPHONE #FAX #FEDERAL TAX I.D. NUMBERMERCHANT E-MAIL ADDRESS (AGENT E-MAIL ADDRESS CANNOT BE ACCEPTED)WEBSITE ADDRESSGO GREEN - OPT IN FOR PAPERLESS STATEMENTS (MUST PROVIDE E-MAIL ADDRESS)TYPE OF OWNERSHIP: SOLE PROPRIETOR PARTNERSHIP CORPORATION LLC NON-PROFIT OTHER:A2MERCHANT PROFILEMERCHANDISE/SERVICE SOLDYEARS IN BUSINESSPERCENT OF BUSINESSLENGTH OF CURRENT OWNERSHIP # OF LOCATIONS MONTHLY VOLUME AVERAGE TICKET AMOUNT HIGHEST TICKET AMOUNT$ $ $HAS MERCHANT OR ANY PRINCIPAL BEEN TERMINATED AS A VISA/MASTERCARD MERCHANT (TMF)?YES NO REASON:HAS MERCHANT OR ANY PRINCIPAL DISCLOSED BELOW FILED BANKRUPTCY OR BEEN SUBJECT TO ANY INVOLUNTARY BANKRUPTCY?YES NO REASON:HAS MERCHANT PREVIOUSLY ACCEPTED CREDIT CARDS? YES NOPROCESSOR:DOES MERCHANT CONDUCT BUSINESS SEASONALLY?PLEASE CONTACT CUSTOMER SERVICE TO DEACTIVATE ACCOUNT DURING SEASONAL MONTHSDOES THE BUSINESS USE ANY THIRD PARTIES IN THE PAYMENT PROCESS?YES NOIF YES, PLEASE LIST:REFUND POLICY:YESNOIF YES, PLEASE PROVIDE COPIES OF MOST RECENT STATEMENTCARD SWIPEDMANUAL KEY WITH IMPRINTMAIL ORDER/TELEPHONE ORDEREach merchant certifies that the average ticket size, highest ticket and sales volume indicated is accurate and acknowledges any variance to this information could result in delayed and/or withheld settlement offunds and/or termination of merchant.E-COMMERCE MERCHANTS ONLYSERVICE PROVIDER:LIST ALL APPLICABLE URL'S FOR YOUR WEBSITE: IF E-COMMERCE, DO YOU USE A FULFILLMENT CENTER? YES NOIF YES, PLEASE LIST CONTACT INFORMATION:TOTALWHEN IS THE CARDHOLDER BILLED FOR PRODUCTS/SERVICES? ON ORDER SHIPMENTDELIVERY OF PRODUCTS: TIME OF SALE 1-3 DAYS 3-5 DAYS 5-15 DAYS 15 DAYS+DETAILED BUSINESS DESCRIPTION:DOES MERCHANT USE A FULFILLMENT HOUSE? YES NODOES YOUR SITE HAVE A SECURE CERTIFICATE? YES NO%%%100%A3PRINCIPAL #1OWNERS OR OFFICERS% OF EQUITY OWNERSHIP PRINCIPAL #2 % OF EQUITY OWNERSHIPSOCIAL SECURITY NUMBERDATE OF BIRTHTELEPHONE #SOCIAL SECURITY NUMBERDATE OF BIRTHTELEPHONE #RESIDENCE ADDRESSRESIDENCE ADDRESSCITY STATE ZIPCITY STATE ZIPA4REFERENCESTRADE REFERENCECONTACT ACCOUNT # TELEPHONE #TRADE REFERENCE CONTACT ACCOUNT # TELEPHONE #A5BANKING INFORMATIONNAME OF MERCHANT'S BANKROUTING/ABA #PLEASE INCLUDE A VOIDED CHECK OR BANK LETTERCONTACT BANK LOCAL TELEPHONE #DBA/CHECKING ACCOUNTIn accordance with the terms set out in the Terms and Conditions, transfer funds will be made to/from the account set forth in the enclosed voided check or bank letter.JUNE12HARBORTOUCH IS A REGISTERED ISO/MSP OF FIRST NATIONAL BANK OF OMAHA, 1620 DODGE ST., OMAHA, NE – FDICPAGE 2 OF 4