Fill Out the Following form completely, then print, and sign at bottom
* Indicates Required Field!

General Information

Legal Name*

Doing Business As:*

Business Address:*

Billing Address:*

How Long:*

City:*

State:* Select ----- AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip: *

City:*

State:* Select ----- AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip:*

County*

Contact Name:

Business Phone:*

Business Fax:

Federal Tax ID:*

# of Locations:

Time in Business:*
Years Months 0 1 2 3 4 5 6 7 8 9 10 11

Business Hours:

E-mail:

Web Site:

Business Information

Type of Ownership:*
Select Sole Owner Corporation LLC Non-Profit Partnership Government Trusts/Estates/Assn.'s Legal/Medical Corp Tax Exempt Org. Int'l Organization Other
If Other, please specify:*


Number of days until Product/Service is delivered:*

Has applicant ever processed before?*
Yes   No
If YES, with whom?*
Has applicant ever been terminated?*
Yes   No
If Yes, by whom?*
(Please provide an explanation regarding your termination below.
Attach additional pages if necessary)

Specific Type of Business:*

Specific Type of Product(s)/Service(s) sold:*

Principal 1

Name:*

Social Security #:*
--

% of Ownership:*

Home Phone:

Date of Birth:*
/ /

Residence Address:*

Own  Rent

City/State:*

Select ----- AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip:*

How Long at address:*
Years     
Months    0 1 2 3 4 5 6 7 8 9 10 11

Drivers License Number/State:*
Select ----- AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Officer's Title:*

Name of Nearest Relative not living with you:

Home Phone:

Address:

City:

State: Select ----- AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip:

Principal 2

Name:*

Social Security #:*
--

% of Ownership:*

Home Phone:

Date of Birth:*
/ /

Residence Address:*

Own  Rent

City/State:*

Select ----- AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip:

How Long at address:*
Years     
Months    0 1 2 3 4 5 6 7 8 9 10 11

Drivers License Number/State:*
Select ----- AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Officer's Title:*

Name of Nearest Relative not living with you:

Home Phone:

Address:

City:

State: Select ----- AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip:

References*

Bank:

Account:

Phone:

Contact:

Trade:

Account:

Phone:

Contact:

Trade:

Account:

Phone:

Contact:

Equipment

Verifone:
Model___________________

Hypercom:
Model___________________

Lipman Nurit:
Model___________________

ECS Terminals
ECS Terminals
Software______________

Other:

Network:

To Be Completed By ECS Sales Rep

Sales Rep Name: Kevin McFadden
Rep#: 333

Over Limit Fee:
5.00%

Debit:
$0.35 + network fees

Monthly Processing
Limit Requested:
$___________________

Average Ticket:
$___________________

Monthly Statement Fee:
$10.00 per month
$_____ per month

Batch Headers:
$.030 each

Monthly Minimum:
$100.00

Application Fee:
$___________________

Transaction Fee
(local 950):
$0.20  each
$0.30  each
$____ each

Voice Auth.
$2.00 each

Chargebacks:
$25.00 each

Swipe:
Discount Rate Requested:
________%

Mid-Qualified Rate:
Discount +1.00%

Non-Qualified Rate:
Discount +1.50%

Keyed:
Discount Rate Requested:
________%

Mid-Qualified Rate:
Discount +0.50%

Non-Qualified Rate:
Discount +1.20%

Watts Auth. Trans Fee:
$0.45 each

EBT:  $0.10 each

AVS:  $0.10 each

Monthly Access Fee:
VT/VT

$____ per month

Funds Availability:
1 day
3 days
5 days
7 days

Reserve Rate:
None
5.00%
____%

Retrieval Request Recv'd:
$7.00 each

VT/VT Trans Fee:
$0.___each

High Risk Registration Fee: $1000.00
(if applicable)

VT Discount Rate:
_____%

Merchant Number

AMEX #:

Capture
Draft

Diners#:

Capture
Draft

Discover #:

Capture
Draft

Other#:

Capture
Draft

Signatures/Authorization to ACH*
Please Attach a Voided Check

Bank Name:

Street Address:

City:

State: Select ----- AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip:

Branch:

Phone:

Officer Name:

Transit # (ABA Routing):

Account # (DDA):

MERCHANT acknowledges that ECS and/or BANK as referenced above, will determine all Rates, Charges, Reserves and Limit Authorizations, collectively "Fees". Bank will notify MERCHANT of the approved Fees and MERCHANT, by evidence of MERCHANTS first settled transaction, agrees to such approved Fees. MERCHANT and each Personal Guarantor warrants and certifies that all the information submitted under this application is true, correct and complete and that ECS and BANK are relying on such information in its approval process and in setting the applicable Fees. For this purpose, MERCHANT and each Personal Guarantor, if any, agree that BANK/ECS are authorized to investigate and confirm the information contained or submitted herein and may utilize credit bureau/agencies and/or its own agents. MERCHANT agrees and understands that the Merchant Processing Agreement shall not take effect until the MERCHANT has been approved by BANK and a Merchant Number has been issued.
For MERCHANTS that select the ECS Terminals and enter into an ECS Terminals Service Agreement with ECS ("Service Agreement"), the Service Agreement provides that should payment for any and all lees and charges under the Service Agreement not be made within fifteen (15) days of the date of any invoice, MERCHANT authorizes ECS to electronically debit by way of any automated clearing house ("ACH") transaction, the Designated Account, as defined below, of MERCHANT, for all fees, costs and charges due ECS, By completing and executing the ACH Authorization Form above, and by execution of this Application, MERCHANT expressly authorizes ECS to make any and all such ACH debits from the Designated Account of MERCHANT, and expressly instructs its financial institution at which MERCHANT'S Designated Account is maintained: to allow all such ACH debits on ECS' behalf. In addition, MERCHANT grants ECS a specific security interest in all Merchant Account Reserves, as defined in the Service Agreement, maintained by MERCHANT at any financial institution, and hereby authorizes ECS to debit and/or offset any invoiced amounts not paid within fifteen (15) days. In the event of an ACH debit or offset, ECS will provide MERCHANT with an itemized statement detailing the transactions and related ACH debits or offset for the calendar month immediately preceding. This ACH Authorization shall remain in effect at all times during the term of the MERCHANT's ECS Service Agreement, or until such time as all outstanding obligations of MERCHANT to ECS arising under the Service Agreement are paid in full, whichever is longer "Designated Account" for purposes of the ECS Service Agreement shall mean the financial institution and account designated in the space above.

Merchant Authorized Signature:*

_________________________

Date:*

Merchant Authorized Signature:*

_________________________

Date:*

Merchant Site Survey *Photograph of business location (interior & exterior) are required. (Completed by ECS sales representative)

Specific Business Type

Type of Building

Square Footage
(Approximate):

Merchandise Sold

Inspector's Comments

Inspector's Signature

Date