ACCOUNT SETUP FORM - United Bank Card

ACCOUNTSETUP/PLACEMENT FORMPlease submit both pages ofthis form along with the MerchantApplication and all supportingdocumentation by email toapps@harbortouch.comor via fax to 908-730-7437OFFICE ID:PLEASE SELECT ONE (REQUIRED):OPTION 1 OPTION 2 OPTION 3IF AN OPTION IS NOT SELECTED, THE ACCOUNT WILLDEFAULT TO OPTION 1MERCHANT INFORMATION:MERCHANT DBA:MID:NEW ACCOUNTEXISTING ACCOUNTSELECT EQUIPMENT TYPE:*FREE PERKWAVE TERMINALCONNECTION TYPE:DIALIPOTHER OPTIONS:ADD ADDITIONAL: x $79.00 ANNUAL FEEADD P-1300 PIN PAD - $89.50*MOTO accounts will not receive the NFC readerA Merchant enrolled in the FT Program will receive a Perkwave Terminal ("Terminal"). The Terminal is and will remain at all times the exclusive property of Harbortouch. Under the FT Program, Merchant is eligible to receive a new Terminal if Merchant'sTerminal breaks, in Harbortouch's sole discretion due to normal wear and tear. Merchant will receive a priority replacement, comparable Terminal so long as Merchant processed an electronic transaction through Harbortouch within fifteen (15) days ofequipment failure. Merchant will pay all shipping costs. Additional fees and charges may apply for failure to return Terminal following replacement of equipment or termination of the Merchant Transaction Processing Agreement. Please See MerchantTransaction Processing Agreement for complete Terms and Conditions.FREE CASIO ELECTRONIC CASH REGISTERCONNECTION TYPE: DIAL IPNUMBER OF REGISTERS:A Merchant enrolled in the ECR Program will receive one Electronic Cash Register (ECR) and one Credit Card Processing Device, (collectively referred to as "Equipment"). If placement is selected, equipment is and will remain at all times, the exclusiveproperty of Harbortouch. A $79.00 Annual Fee will apply for each set of Equipment sent to Merchant. Shipping charges will apply. As a condition of approval a $99.00 Security Fee may apply. Additional fees and charges may apply for failure to returnEquipment following replacement of equipment or termination of the Merchant Transaction Processing Agreement. Please See Merchant Transaction Processing Agreement for complete Terms and Conditions.FREE S90 WIRELESS TERMINALMERCHANT EMAIL ADDRESS (REQUIRED):ADD ADDITIONAL:ADD IMPRINTER - $35.00x $79.00 ANNUAL FEE*A Merchant enrolled in the FT Program will receive a Wireless Terminal ("Terminal"). The Terminal is and will remain at all times the exclusive property of Harbortouch. Under the FT Program, Merchant is eligible to receive a new Terminal if Merchant'sTerminal breaks, in Harbortouch's sole discretion due to normal wear and tear. Merchant will receive a priority replacement, comparable Terminal so long as Merchant processed an electronic transaction through Harbortouch within fifteen (15) days ofequipment failure. A $79.00 Annual Fee will apply for each set of Equipment sent to Merchant. Merchant will pay all shipping costs. Additional fees and charges may apply for failure to return Terminal following replacement of equipment or termination ofthe Merchant Transaction Processing Agreement. Please See Merchant Transaction Processing Agreement for complete Terms and Conditions.SELECT MOBILE/SOFTWARE PROGRAMS:AUTHORIZE.NETADD E-CHECKS(SEPARATE PRICING & CONTRACT REQUIRED)ADD FRAUD SCREENING(SEPARATE PRICING & CONTRACT REQUIRED)SETUP FEE (COLLECTED BY SALES AGENT) $GATEWAY ACCESS FEE$BUSINESS TYPE: RETAIL MOTO/E-COMMERCEE-MAIL ADDRESS:PER TRANSACTION FEE $BATCH FEE $CHARGE ANYWHERE MOBILE SOLUTIONSAUDIO JACK MAG STRIPE READER(APPLE, BLACKBERRY, ANDROID) - FREEBLUETOOTH PRINTER/MAG STRIPE READER(ANDROID, BLACKBERRY, WINDOWS MOBILE) - $249.00APPLE iPhone/iPad PRINTER/MAG STRIPE READER - $259.OOPHONE/TABLET MODEL:WIRELESS PROVIDER:CELL PHONE NUMBER:MONTHLY FEE (PER DEVICE): $TRANSACTION FEE: $PC CHARGE - $99.00 (NEW ACCOUNT PRICING ONLY)ADD USB CARD READER - $79.00ADD PIN-PAD 1000 ADAPTER - $79.50ADDITIONAL USER - $99.00HT2021_10082014PAGE 1 OF 2

ADDITIONAL INFORMATION:TERMINAL FEATURESRETAILDEBIT/CASHBACKIF USING A STATIC IP NETWORK, PLEASE SUPPLY THE FOLLOWING INFORMATION:RESTAURANTLODGINGEBT/CASH BENEFITS - FCS ID:IF NO FCS ID, CASH BENEFITS ONLYIP ADDRESS:GATEWAY IP:SUBNET MASK:DNS SERVER IP:MOTOTIP LINE AUTO BATCH: YES TIME: NOSHIPPING INFORMATIONTERMINAL SHIPPING(PER TERMINAL):FREE GROUND SHIPPING2ND DAY AIR $18.00NEXT DAY AIR $27.00N/AECR SHIPPING(PER REGISTER):GROUND $25.002ND DAY AIR $51.50NEXT DAY AIR $76.95NAME:ADDRESS:CITY: STATE: ZIP:TELEPHONE NUMBER:SHIPPING PAYMENT INFORMATIONACHCREDIT CARDCREDIT CARD NUMBER:EXPIRY DATE:CVV2:SIGNATURE:SPECIAL INSTRUCTIONS (SUBJECT TO APPROVAL)Merchant has indicated which additional optional services it is requesting. Merchant agrees that Harbortouch is not a party to any of the optional servicesindicated herein and has no liability related to those services. Merchant must be approved by each company and each company may send its terms andconditions (electronically or by physical mail) to the Merchant upon such approval. Merchant agrees to be bound by such company’s terms and conditions.By their execution below, the undersigned parties agree to abide by the Merchant Transaction Processing Agreement (the "AGREEMENT"). TheAGREEMENT consists of the Merchant Application and the Terms and Conditions (a separate attachment hereto), and MERCHANT acknowledges it hasreceived and read the Terms and Conditions at the time of signing. Merchant further acknowledges that it has received, read, and understood any terms andconditions related to third party products and services. In witness whereof the party hereto has caused this agreement to be executed by its duly authorizedrepresentative.xMERCHANT SIGNATUREDATE© 2014 Harbortouch Payments, LLC. All rights reserved.PAGE 2 OF 2