ACCOUNT SETUP FORM - United Bank Card

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