Merchant Services Application (Page 2 of 2) in pdf

Page 3 of 7

OTHER PRODUCTS AND SERVICES

Merchant elects acceptance of the following services:

ACCESS.NET (Web Reporting)

Merchant Gift Cards

Electronic Check Service

EWI

Do you wish to also submit this document as an application for a:

Yes

Business Credit Express Line of Credit?

Yes

Platinum Visa Business Card?

Power Rewards Business Card?

Yes

APPLICABLE ONLY IF MERCHANT IS APPLYING FOR THE PRODUCTS ABOVE: We may share information about the business and the undersigned owners and officers with FIA Card

Services, N.A. for consideration of the product(s) checked above. The undersigned owner(s) and officer(s) listed in Section 2 below agree(s) that the application will be procesed on behalf of all

owners and officers, each of whom has signed below, and on behalf of the business. Each owner listed in Section 2 below further acknowledges receipt of and agrees to be bound by the applicable

Small Business Fee and Term information provided to you as part of this Merchant Services Application.

2. BUSINESS OWNERSHIP INFORMATION

FORM OF OWNERSHIP (Mandatory)

Sole Proprietorship

Partnership

Limited Partnership

Non US Company

Government

Multi Member Limited Liability Company

Symbol

Single Member Limited Liability Company

Tax Exempt Organization

Corporation (privately traded)

Corporation (publicly traded)

OWNER/OFFICER INFORMATION

Information on the individual(s) signing the Application must be provided below .

OWNER (% Ownership

1. FIRST NAME, MI, LAST NAME

TITLE

DATE OF BIRTH:

)

OFFICER

HOME ADDRESS

CITY

STATE

ZIP

GOVERNMENT ISSUED ID #

DATE ISSUED

EXPIRATION DATE

STATE ISSUED

COUNTRY OF ISSUANCE (IF NOT U.S.)

TYPE OF ID

TELEPHONE

SOC. SEC. #

COUNTRY OF CITIZENSHIP (IF NOT U.S.)

OWNER (% Ownership

)

2. FIRST NAME, MI, LAST NAME

TITLE

DATE OF BIRTH:

OFFICER

HOME ADDRESS

CITY

STATE

ZIP

GOVERNMENT ISSUED ID #

DATE ISSUED

EXPIRATION DATE

STATE ISSUED

COUNTRY OF ISSUANCE (IF NOT US)

TYPE OF ID

TELEPHONE

SOC. SEC. #

COUNTRY OF CITIZENSHIP (IF NOT U.S.)

NAME OF CORPORATE/PARENT OWNER

If corporate/parent ownership: list information below:

CONTACT NAME

E-MAIL ADDRESS

ADDRESS

CITY

STATE

ZIP

TELEPHONE

FAX

ALTERNATE TELEPHONE

GENERAL PROVISIONS

APPLICABLE ONLY IF MERCHANT ACCEPTS AMERICAN EXPRESS: I authorize American Express Travel Related Services Company, Inc (American Express”) to verify the information on this Application and to receive and

exchange information about me, including, requesting reports from consumer reporting agencies. If I ask American Express whether or not a consumer report was requested, American Express will tell me, and if American Express received a

report, American Express will give me the name and address of the agency that furnished it. I understand that upon American Express' approval of the business entity indicated above to accept the American Express Card, the Terms and Conditions

for American ExpressCard Acceptance ("Terms and Conditions") will be sent to such business entity along with a Welcome Letter. By accepting the American Express card for the purchase of goods and/or services, I agree to be bound by the

Terms and Conditions.

APPLICABLE ONLY IF MERCHANT ACCEPTS DISCOVER: By signing below or providing my assent to this Application, I represent that the information provided on this Application is complete and accurate. I hereby request that

Discover Card acceptance be added to my Merchant Application. I understand that the Terms and Conditions for Discover Card Acceptance (Terms and Conditions) will be sent to the business indicated above upon approval by Discover Financial

Services, Inc. for this business entity to accept the Discover Card. By accepting the Discover Card for the purchase of goods and/or services, I agree to be bound by the Terms and Conditions.

APPLICABLE TO ALL MERCHANTS: MERCHANT REPRESENTS THAT THE MERCHANT HAS CHOSEN FOR ITSELF ANY SERVICES, EQUIPMENT OR THIRD PARTY SELECTED IN CONNECTION WITH THE

AGREEMENTS AND MERCHANT'S DECISION WAS SOLELY BASED ON MERCHANT'S OWN CRITERIA AND ANALYSIS. MERCHANT NOW AND FOREVER EXPRESSLY DISCLAIM ANY RELIANCE UPON PROMISES OR

REPRESENTATIONS, UNLESS SPECIFICALLY INCORPORATED HEREIN IN WRITING, MADE BY BANK OFAMERICA, N.A. (“BANK”), SALES REPRESENTATIVES OR OTHERS RESPECTING THE FUNCTIONALITY,

OPERABILITY, COMPATIBILITY, ETC. OF THE EQUIPMENT OR SERVICES. MERCHANT AGREES TO HOLD BANK HARMLESS FROM AND AGAINST ANY AND ALL CLAIMS, DAMAGES AND LIABILITIES ARISING

OUT OF THE NEGLIGENCE OR WILLFUL MISCONDUCT, ACTS AND/OR OMISSIONS BY MERCHANT OR ANY THIRD PARTY ENGAGED BY MERCHANT, INCLUDING THE EMPLOYEES AND/OR AGENTS OF

MERCHANT OR SUCH THIRD PARTY.

The completed Application, the Merchant Agreement, the Fee Schedule, any forms and/or forms attached below and the Rules/Manuals/Instructions (collectively the “Agreement”) constitute the entire agreement between the parties with respect to

the subject matter and supersede any prior agreements or understandings. By 1. signing below or 2. providing email approval or 3. providing electronic approval or 4. submitting transaction data, Merchant affirms its understanding and acceptance

of the Agreement, which is incorporated herein by reference as if fully set forth here, and that Merchant has received a complete copy of the Agreement. Merchant acknowledges that: (a) no handwritten changes have been made to the printed text

of the Agreement and (b) the parties may produce and rely on a copy or electronically stored image of the Agreement for all legal purposes. Further, Merchant expressly warrants that the information provided in the Application is true, accurate and

complete, and that Bank may rely on it, without further investigation, for all purposes.

1. Person(s) who sign below or 2. person(s) returning this Application in an electronic format further unconditionally authorizes Bank, or its agents to investigate the information and references contained herein, and to obtain additional information

about the Merchant, as well as individual persons and companies named in this Application, from consumer and business credit bureaus and other lawful sources. The undersigned further authorizes Bank to provide to any governmental,

administrative or regulatory entity, as well as any vendor or affiliate of Bank, including the applicable referrer, Independent Sales Organization, Member Service Provider, or Associated Sales Group, any information about Merchant, whether

independently obtained by Bank or provided by Merchant, that Bank deems reasonably necessary or connected to the provision of services contemplated in the Agreement, upon request from such entity, vendor or affiliate or in compliance with

applicable law, including the USA PATRIOT Act,. If Merchant is a franchisee or member of a corporate association, and Merchant is receiving preferential pricing and/or other benefits as a result of Merchant's relationship with that entity, then

upon the request of that entity, Bank may provide that entity any information about Merchant that Bank deems reasonably necessary or connected to the provision of services contemplated in the Agreement.

IN WITNESS WHEREOF, the parties cause the Application and the applicable Agreement to be executed by their duly authorized owners and/or officers.

("MERCHANT") (Business Name -

BANK OF AMERICA. N.A. ("BANK")

print or type)

Signature: _________________________________________________________

Name

(print or type)

Title

Date:

Title

Date:

(print or type)