Merchant Services Application

All Fields Are Required Unless Otherwise Indicated. Any Incomplete Or Inaccurate Information Will Delay The Processing Of Your Application And May Result In A Decline.

Merchant Business Information
Business Legal Name: (Must Match Business Tax Return Name)*
Business Name (DBA):*
Check here if Corporate Headquarters
Business Location Address:*
Street Address Address Line 2 City State ZIP Code
Location Phone #:*
Location Fax #:*
Business Billing Address (If Different From Location Address):
Street Address Address Line 2 City State ZIP Code
Location Phone #:*
Location Fax #:*
Contact Name*
First Last
Contact E-Mail Address:*
Business Website Address:*
Federal TAX ID # (as it appears on your income tax return)*
Section 2 Beneficial/Control Ownership Information
To help the government fight financial crime, Federal regulation requires certain financial institutions to obtain, verify, and record information about the beneficial owners of certain legal entity customers. Legal entities can be abused to disguise involvement in terrorist financing, money laundering, tax evasion, corruption, fraud, and other financial crimes. Requiring the disclosure of key individuals who own or control a legal entity (i.e., the beneficial owners) helps law enforcement investigate and prosecute these crimes.
Type of Legal Entity
- Association/Estate/Trust
- Government (Federal/State/Local)
- Individual/Sole Proprietor
- Financial Institution
- LLC
- Non Profit/Tax-Exempt (501C)
- Partnership
- Private Corporation
- Publicly Traded Corporation
- SEC Registered Entity
Control Owner/Officer/Principal Name:*
Title*
DOB:
MM slash DD slash YYYY
SSN #
Ownership Percent
Please enter a number from 0 to 100.
Home Address
Street Address City State / Province / Region ZIP / Postal Code Country
Phone
Beneficial Owner/Officer/Principal Name:
Title*
DOB:
MM slash DD slash YYYY
SSN #
Ownership Percent
Please enter a number from 0 to 100.
Home Address
Street Address City State ZIP Code
Phone
Beneficial Owner/Officer/Principal Name:
Title*
DOB:
MM slash DD slash YYYY
SSN #
Ownership Percent
Please enter a number from 0 to 100.
Home Address
Street Address City State ZIP Code
Phone
Beneficial Owner/Officer/Principal Name:
Title*
DOB:
MM slash DD slash YYYY
SSN #
Ownership Percent
Please enter a number from 0 to 100.
Home Address
Street Address City State ZIP Code
Phone
7. SIGNATURE(S)
IMPORTANT MEMBER BANK RESPONSIBILITIES: (1) A Visa Member is the only entity approved to extend acceptance of Visa products directly to a Merchant. (2) A Visa Member must be a principal (signer) to the Merchant Agreement. (3) The Visa Member is responsible for educating Merchants on pertinent Visa Operating Regulations with which Merchants must comply. (4) The Visa Member is responsible for and must provide settlement funds to the Merchant. (5) The Visa Member is responsible for all funds held in reserve that are derived from settlement.

IMPORTANT MERCHANT RESPONSIBILITIES: (1) Ensure compliance with cardholder data security and storage requirements. (2) Maintain fraud and chargeback below thresholds. (3) Review and understand the terms of the Merchant Agreement. (4) Comply with Operating Regulations. The responsibilities listed above do not supersede the terms of the Merchant Agreement and are provided to ensure the Merchant understands some important obligations of each party and that the Visa Member (Acquirer) is the ultimate authority should the Merchant have any problems.
Title*
Date*
MM slash DD slash YYYY
Signature*
SECTION 4 BUSINESS PROFILE AND ASSUMPTIONS
- Ownership or Legal Entity Change
Close NPC Existing MID#
Close Date Existing MID:
MM slash DD slash YYYY
Open Date
MM slash DD slash YYYY
Annual Volumn (Visa/MC/DS/AX):
% Card Present
Please enter a number from 0 to 100.
% Card Swipe
Please enter a number from 0 to 100.
% Imprint (Manually Keyed)
Please enter a number from 0 to 100.
% B2B
Please enter a number from 0 to 100.
Average Ticket (Visa/MC/DS/AX):
% Card Not Present
Please enter a number from 0 to 100.
% MOTO
Please enter a number from 0 to 100.
% Internet
Please enter a number from 0 to 100.
% of International Cards
Please enter a number from 0 to 100.
Highest Ticket (Visa/MC/DS/AX):
Total 100%
Please enter a number from 0 to 100.
- Add'l. Location
1st Location MID:
Refund Policy (select one):
- No Refund
- Refund in 30 days or less
- Merchandise exchange only
- Other
Seasonal Sales
- Yes
- No
Active Months
- JAN
- FEB
- MAR
- APR
- MAY
- JUN
- JUL
- AUG
- SEP
- OCT
- NOV
- DEC
Section 5 Compliance Information
Do you (MERCHANT) have a
- 3rd party Software application/gateway or
- POS Terminal
Do you store cardholder data? Paper?
- YES
- NO
Electronic
- YES
- NO
Have you ever experienced an Account Data Compromise?
- YES
- NO
If yes, have you completed remediation?
- YES
- NO
Third Part Software/Gateway Vendor Name and Address
Third Party Software/Gateway Vendor Contact Information:
Version #
Merchant data to which this vendor has access:
Does software store cardholder information?
- YES
- NO
All merchants must comply with the Payment Card Industry Data Security Standard ("PCI DSS"). Merchant is required to maintain the security of card data and to comply with the requirements of the PCI DSS. Merchant must validate its compliance with the PCI DSS and provide NPC with evidence that Merchant (a) has successfully completed a Self Assessment Questionnaire and scan(s), if applicable, and (b) is compliant with the PCI DSS. NPC has created the PCI Program (the "PCI Program") to assist merchants in securing card data and complying with PCI DSS. You are enrolled in the PCI Program and the applicable fees will be assessed in accordance with the terms of the PCI Program. Information on the PCI Program is set forth in Section 15 of the Terms and Conditions and the applicable fees are set forth in Section 8 of this Application. All gateway or other vendor supplied software must be compliant with the Payment Application Data Security Standard rules ("PA DSS").
SECTION 6 MERCHANT BANK ACCOUNT INFORMATION
In accordance with the terms set out in the Merchant Processing Agreement, funds will be transferred to/from the account as delineated. If nothing is checked, MERCHANT will receive Premium ACH. ACH can be performed by the following entities: Member Bank, NPC or any authorized agent of NPC or any Third Party Service Provider with whom you have contracted. *Subject to special approval.
Deposit Time Frame:
- Premium ACH
- Alternate Funding
Deposit Type
- Combined
- By Batch
Any ACCOUNT NUMBER indicated must be a valid account number for handling ACH deposits and withdrawals. If more than one account is indicated, account #1 will be used for Sales.
Routing #1
DDA Account Type
- Checking
- Savings
Account #1
Routing #2
DDA Account Type
- Checking
- Savings
Account #2
If second account, this account is used for:
- Discount
- Fees
- Credits
- Chargebacks

Debit Adjustment Fee	$5.00/Adjustment	Paper Statement Fee	$0.00
Dialpay Transaction Fee	$0.55/Transaction	Technical Support Calls	$0.00
Chargeback Fee	$12.00/Chargeback	Customer Services Calls	$0.00
Retrieval Fee	$5.00/Retrieval	Merchant Monthly Minimum	$15.00
Batch Fee	$0.07/Batch	Welcome Kit	$6.50
Online Statements and Reporting	$0.50/mo	ACH/DBA Change Fee	$5.00
Voice Authorization	$1.35/Attempt	Merchant Training (Only By Request)	$15.00
Online Payment Processing		Merchant Download¹	$14.00/Download
– One-Time Activation	$59.00	PCI Program	$55.00/yr
– Gateway Hosting Fee	$9.95/mo	PCI Non-Compliance Fee	$25.00/mo
– Transaction Fee	$0.05/Transaction (+ front end transaction fee)	Voyager	3.60% + $0.15
– Batch Fee	$0.07/Batch	Wright Express (WEX)	3.50% + $0.15
Wireless POS		ACH Fee	$0.02/ACH
– One-Time Activation	$40.00/Terminal	ACH Reject Fee	$25.00
– Gateway Hosting Fee	$17.95/Terminal/mo	Electronic Benefit Transfer (EBT)
– Transaction Fee	$0.09/Transaction (+ front end transaction fee)	– Transaction Fee	$0.05/Transaction
Mobile POS		– EBT ACH	$3.00
– Monthly Hosting Fee	$9.95/mo	– EBT Adjustments	$5.00
– Transaction Fee	$0.12/Transaction (+ front end transaction fee)	Credit Tier II Surcharge	0.05%
Micros Transaction Fee	$0.05/Transaction (+ front end transaction fee)	Advantage Buyer Program	$19.95/mo
Address Verification Fee	$0.02/Verification

Merchant Services Application

Merchant Business Information

Section 2 Beneficial/Control Ownership Information

7. SIGNATURE(S)

SECTION 4 BUSINESS PROFILE AND ASSUMPTIONS

Section 5 Compliance Information

SECTION 6 MERCHANT BANK ACCOUNT INFORMATION

Western Financial

Fees