Merchant Services Application

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P#

BANK OF AMERICA, N.A.

MERCHANT SERVICES APPLICATION

1.

MERCHANT BUSINESS INFORMATION

(If P.O. Box, Physical Location Is Also Needed)

LEGAL BUSINESS NAME

CONTACT NAME

DBA NAME

PHYSICAL ADDRESS (INCLUDE CITY, STATE AND ZIP)

Check here if Mailing Address is the same as Physical Address

MAILING ADDRESS (INCLUDE CITY, STATE AND ZIP)

PLACE OF LEGAL FORMATION

COUNTRY OF PRIMARY BUSINESS OPERATIONS

PRIMARY TELEPHONE

ALTERNATE TELEPHONE

FAX

E-MAIL ADDRESSES OF ALL PERSON(S) SIGNING THIS APPLICATION

CUSTOMER SERVICE PHONE #

INTERNET WEBPAGE ADDRESS

FEDERAL TAX ID

Check here if Merchant has applied for Federal Tax ID but has not received

If you are submitting your Federal Tax ID with this application by any method other than mail or in person, such as facsimile or through the Internet, be certain that your connection is secure. Alternatively, you

may provide this information verbally to your sales representative.

Statements to be sent to corporate/parent rather than primary address listed above.

CERTIFICATION OF MERCHANT'S BUSINESS

YEARS/MONTHS IN BUSINESS

YEARS UNDER CURRENT OWNERSHIP

PRODUCTS/SERVICES SOLD

BUSINESS ENVIRONMENT (Check All That Apply)

Storefront

Kiosk

Seminar

In Home

MO/TO

Office

Door to Door

Trade Show/ Flea Market

Job/Service Site

Internet

Business to Business

Other

MERCHANT SETTLEMENT ACCOUNT INFORMATION

Unless this is a Bank of America Account, an Imprinted, Encoded, Voided check or Verification of Account Letter from the bank must be attached. If not

provided account cannot be set up.

FINANCIAL INSTITUTION

TRANSIT/ABA #

ACCOUNT #

If you are submitting your demand deposit account information with this application by any method other than mail or in person, such as facsimile or through the Internet, be certain that

your connection is secure. Alternatively, you may provide this information verbally to your sales representative.

If the Settlement Account listed above is not a Bank of America account, please list a Bank of America account (if Merchant has one) for reference purposes.

ACCOUNT TYPE

LENGTH OF RELATIONSHIP

CONTACT NAME

TRANSIT/ABA #

ACCOUNT #

BANK OF AMERICA RELATIONSHIP DESCRIPTION

Previous processor name:

Has Merchant previously processed VS/MC?

YES

NO

Reason for closure:

If current/previous processor is Bank of America, list Merchant ID #

Total Visa/MC Annual Volume - All Locations processing with Bank of

Average Visa/MC Ticket - Primary Location

Average Monthly Visa/MC Sales:

America

Projected monthly check sales

Occasional Visa/MC Higher Tickets To:

Total Projected Monthly Sales from All Payment Types:

Projected Monthly Sales from Gift Cards/Gift Certificates:

Percentage of Delayed Delivery greater than 30 days

REFUND POLICY (Check One):

No refund

Refund in 30 days or less

Merchandise exchange only

Other (please explain)

Is Merchant's business seasonal?

Yes

No If yes, list inactive months:

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Yes

No If yes, list name:

Is a fulfillment house used?

Address:

City:

State:

Zip:

Telephone:

When is the Merchant's customer billed? (Check one)

On order

On inventory verification

On shipment

Where is the Merchant's inventory housed?

+

% Card Presented

% Card Not Present

% Card Swiped

% Hand Entered (Manually Keyed)

(MUST EQUAL 100% TOTAL)

% MO/TO (Catalog)

% Internet

THIS SECTION IS MANDATORY IF REQUESTING PIN-BASED DEBIT CARD SERVICE

WILL MERCHANT OFFER CASH BACK?

YES

NO

MAXIMUM AMOUNT $

Merchant elects acceptance of the following Card types (additional Card types listed on the Fee Schedule):

All Visa/MC Card types

All Visa cards

All MasterCard cards

American Express

Diner's Club

Visa credit cards only

MasterCard credit cards only

Discover

PIN-Based Debit

Visa off-line debit cards only

MasterCard off-line debit cards only

JCB

EBT

Purchasing Cards

Bank of America Merchant Services Application (Small Business) (10-31-07)

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