Central payment us
2350 Kerner Boulevard, Suite 300
San Rafael, CA 94901
1-888-550-9262
www.cpayus.com
Merchant Account # (Office Use Only)
Agent #
Sales Director
MERCHANT PROCESSING APPLICATION & AGREEMENT
New SetupChange of OwnershipAdd Location
Agent Initials
GENERAL INFORMATION
Legal Business Name (As it appears on the Voided Check):
Doing Business As Name (As it appears on the receipts):
DBA Address: (Street Address other than PO Box)
City:
State/Zip:
DBA Business Phone:
Contact Name:
Fax Number:
Hours of Operation:
Business Open Date: (MM-DD-YYYY)
Not Set
Send Merchant Statements to:
Legal AddressDBA Address
Business E-Mail: (Required)
Business Website:
9 Digit Federal Tax ID (Required):
SSNEIN
SSN Number
EIN Number
BUSINESS INFORMATION
Retail Swiped %
Retail Keyed %
eCommerce %
Mail Order %
TOTAL %
Business Location:
Store Front:Office:HomeOther (specify):
Requested Monthly Sales Limit: $
Requested Highest Ticket: $
Average Ticket: $
MCC/SIC:
Type of Ownership:
Sole Prop.Tax ExemptGov’t.Corp.LLCNon-ProfitPartnershipOther (specify):
Other (specify):
Return Policy:
Refund w/in 30 daysExchange OnlyNoneOther (specify):
Other (specify):
Specific Type of Product(s)/Service(s) Sold:
Merchant Type:
RetailUtilityPetroleumRestaurantMail/PhoneProf. ServicesRetail w/ TipInternetConvenienceLodgingPublic SectorQuick ServeBusiness to Business
Business to Business: B-2-B: %
Business to Business: B-2-C: %
Mail, Telephone or Internet Sales: Who performs product/service fulfillment?
MerchantVendor/Fulfillment House
Vendor/Fulfillment House Information:
Info:
Is applicant currently processing credit cards?
YesNo
(Provide previous processors statements)
Has Applicant ever had a previous credit card processor terminate its merchant account?
YesNo
If Yes, by whom?
BANKING
Bank Name:
Telephone:
9 Digit Routing Number:
Account Number: (Please print legibly)
FUNDS TRANSFER: In accordance with the terms set out in the Terms and Conditions, transfer funds will be made to/from the account set forth in the banking fields above or the attached voided check or bank letter.
PRINCIPAL INFO.
Principal #1 Name:
Social Security Number (Required):
% Ownership:
Date of Birth:
Not Set
Title: OWNER
Residential Address:
City:
State:
Zip:
Home Phone:
Principal #2 Name:
Social Security Number (Required):
% Ownership:
Date of Birth:
Not Set
Title:
Residential Address:
City:
State:
Zip:
Home Phone:
REF.
Trade:
Account #:
Phone:
Contact:
VISA DISCLOSURE
Member Bank Information
First National Bank of Omaha
1620 Dodge Street
Omaha, Nebraska 68197
800-853-9586
Important Member Bank Responsibilities
1. The Visa Member is the only entity approved to extend acceptance of VISA products to a Merchant
2. The 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.
Merchant Information
Merchant Name:
Merchant Address:
Authorized Signature:
Select File
Authorized’s Printed Name:
Important Merchant Responsibilities
1. Ensure compliance with cardholder data security and storage requirements
2. Maintain fraud and chargebacks below thresholds
3. Review and understand the terms of the Merchant Agreement.
4. Comply with VISA 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.
SITE SURVEY
Type of Building:
Square Footage (approximate):
Did the agent meet with the business owner in person?
YesNo
Does the interior of the business reflect the types of products or services sold?
YesNo
Does the business have proper signage clearly indicating the DBA?
YesNo
Under the penalty of perjury and accountability, I hereby certify I personally conducted this premises inspection described above and hereby certify that this business is legitimate and have verified the identification of the above listed principal(s):
Sales Representative Signature:
Select File
Sales Representative Name:
Central Payment is a registered ISO/MSP of First National Bank of Omaha, Omaha, NEPage 1 of 3v0616ISOD
Bank is not a party to this Section and has no liability related to this Section
EQUIPMENT SETUP/ORDER FORM
Purchase: $FT ProgramExisting Terminal
Purchase: $
The undersigned MERCHANT agrees to pay Shipping & Handling on the initial shipment of the designated FT equipment below. Upon request of termination of services prior to the completion of the 36 month equipment commitment, the undersigned MERCHANT agrees to return all provided equipment to Central Payment within thirty (30) days or will be subjected to the debit for the amount of $395 as cost of provided terminal and $200 for the cost of provided PINpad. Merchants using a FT wireless terminal will be subject to the monthly wireless fee as well as a $59 Annual Fee. Merchant is responsible for any local Sales or Use Tax on the cost of the equipment and will be debited separately once equipment is shipped.
Merchant Signature
Select File
Date
Not Set
Restaurant POS
Enterprise equipment built for restaurants • $70 monthly service fee • Setup form required
RiO
Register in One: Receipt printer, cash drawer, bar code scanner, flip touchscreen • Setup form required
Mobile Reader
Audio jack card reader plugs into your existing smart phone or tablet. Compatible with both Apple and Android devices.
Vx520
Supports EMV & NFC
Dial (Prefix: __________ )IP (High speed internet)
Prefix:
Vx680
Wireless solution with 3G internet and built-in receipt printer. Supports EMV & NFC, multi merchants, and internal PINpad. • $12 monthly wireless fee
PayHub VT
Browser-based virtual terminal • $5 monthly fee Retail merchants pay an additional 4 cents per authorization.
PINpad Swap:
By choosing the option to “SWAP” the PINpad, the merchant is subject to a $30 Encryption Fee. Central Payment will deploy a PINpad to the merchant with the Central Payment proprietary encryption that is compatible with the listed terminal. The merchant must exchange or SWAP their preexisting external PINpad with Central Payment’s PINpad within 15 business days or the Merchant’s account will be debited $200 for the cost of Central Payment’s PINpad. May also be subject to shipping charges.
Conversion POS
Software
Version #
Reseller Contact
Telephone
Email:
QuickBooks
QuickBooks POSQuickBooks: Pro, Premier, Enterprise, Accountant
Verosa agreement required. Software must be 2009 or newer. Gateway fees apply.
Indicate the Terminal Profile you want for your equipment:
PIN Debit (PINpad required)Server NumberGratuity GuideTiplineTip PromptCVV2 PromptAVS Prompt ($0.05 per)Invoice NumbersCash BenefitsEBT:Auto Close
EBT:
Existing 7 Digit EBT Number
Auto Close
Time
AMPM
How would you like your equipment shipped?
SHIP TO:
Sales RepresentativeMerchant Legal AddressMerchant DBA AddressOther:
Other:
SHIP METHOD***:
Priority OvernightStandard Overnight2-Day Express Delivery3-Day Express DeliveryGround
***Shipping charges may apply
How did you hear about our services?
Business Name of Referral:
Contact Name:
Phone Number:
SPOTON
All-in-one marketing program at your fingertips.
Start your SpotOn account by selecting a plan below.
Free: $0/month
Up to 100 customers
Build: $39/month
Up to 300 customers
Grow: $79/month
Up to 1,000 customers • Loyalty tablet included • Our most popular plan!
Amplify: $99/month
Up to 10,000 customers • Loyalty tablet included • All customers above 10,000 are $0.01/customer
Change or cancel your plan anytime: all contracts are month to month; there are no cancellation fees.
Ship To:
Legal AddressDBA Address($19.95 S&H Fee)
E-Mail Address (Will serve as your Username)
Contact Number
Signature
Select File
Date
Not Set
SPOTON & SPS-EFT ACH AUTHORIZATION
MERCHANT hereby authorizes SPOTON/SPS-EFT in accordance with this Service Agreement to initiate debit/credit entries to MERCHANT’S checking account, as indicated per the attached copy of a voided check from same. The authority is to remain in full force and effect until (a) SPOTON/SPS-EFT has received written POTON/SPS-EFT reasonable opportunity to act on it, and (b)all obligations of MERCHANT to SPOTON/SPS-EFT that have arisen under this agreement have been paid in full.
SPS-EFT CHECK SERVICES PROGRAMS
Conversion with Guarantee:
Discount Rate: 1.49%
Transaction Fee: 25¢
Conversion without Guarantee:
Discount Rate: 0.00%
Transaction Fee: 25¢
Traditional:
Discount Rate: 1.49%
Transaction Fee: 25¢
Monthly Minimum: $20.00 Service Fee: $10.00
This Agreement includes all of the terms and conditions contained on the front and ATTACHED RECITALS of this Agreement. This Agreement has been executed on behalf of and by the authorized management of each party as of the DATE BELOW. If either party terminates this 24 month agreement a $199.00 fee will be assessed and electronically debited from the MERCHANT’S account. MERCHANT is responsible for the cost of any shipping.
Merchant Initials:
Select File
Date
Not Set
GIFT CARD PROGRAM
Sign me up for my FREE 3-month trial gift card program.
Gift card processing is enabled for all merchants using compatible processing equipment. After the Initial 3-month trial period, the gift card program is $19.95 monthly.
I have an existing gift card service.
Special Instructions: For Central Payment use only.
Shipping Instructions:
File Build Instructions:
Central Payment is a registered ISO/MSP of First National Bank of Omaha, Omaha, NEPage 2 of 3v0616ISOD
SCHEDULE OF FEES – VISA, Mastercard, Discover and AMEX
To be completed by Sales Representative
TIERED PRICING
Check Card Rate %:
Qualified Rate %:
Mid-Qualified Rate %:
Non-Qualified Rate %:
Transaction Fee ¢:
PASS-THROUGH PRICING*
IC + %
Transaction Fee ¢:
* Applies to Amex pricing
AMEX OPT-BLUE*
Qualified Rate%:
Non-Qualified Rate %:
Transaction Fee ¢:
* AMEX: + % for Manual Entry
PIN-DEBIT (PINpad Required)
Network Fee %:
Transaction Fee ¢:
APPLICATION & SETUP FEE $
MISCELLANEOUS FEES
Monthly Statement Fee: $
Monthly Minimum: $
Def: $25-(Total Discount Fees)= Amount Billed (if any)
Per Batch Fee: $
Per Chargeback/Retrieval Fee: $25.00
Most common causes for downgrades to Mid-Qualified are accepting Rewards cards. Most common causes for downgrades to Non-Qualified are accepting Manual Entry, Sale Amount (AMEX Opt-Blue), Business, Corporate, Commercial cards, or not settling within 24 hours.

The following fees will be passed through at Association’s rate: Assessments, MasterCard Network Access Brand Usage Fee, Visa Network Acquirer Processing Fee, Visa International Acquirer Fee (including High Risk), Discover Data Usage Fee, MasterCard AVS Card Present Fee, MasterCard Account Status Fee, MasterCard AVS Card Not Present Fee, MasterCard Processing Integrity, Visa Debit Transaction Integrity, Visa Fixed Acquirer Network Fee, Discover Network Authorization Fee, MasterCard CVC2 Transaction Fee, All Other Applicable Association Fees. The following fees will also be assessed at Central Payment rates: the MC (MasterCard) Per Location Fee, and the Total System Services Network fee (TSSNF).

A PCI Annual Compliance Fee of $95 will be assessed to the merchant account. If Compliance requirements are not met within the first 2 months of the Agreement, a $23.95 Monthly Non-Compliance fee will be charged to the merchant account, which includes automatic required enrollment to the Card Compromise Assistance Plan, until Compliance is achieved. After compliance is achieved, the Card Compromise Assistance Plan Monthly Fee of $7.95 is optional.
Annual PCI Compliance Fee is billed on the January billing statement of each calendar year. Merchants who have signed up less than 60 days from this date are exempt from the said fee for the year.


Merchant may cancel anytime with no early termination penalty. 30 days advance written notice required.
Paragraph references and capitalized terms not defined in this paragraph are defined in the TERMS & CONDITIONS (@ www.cpay.com/conditions).

MERCHANT has indicated which services it is requesting. MERCHANT agrees that BANK and Central Payment (“CPAY”) are not a party to any agreement for services from the following companies: American Express (See AMEX T&C @www.cpay.com/amexterms), Discover Network, Diners Club,SPS-EFT, PayHub, PayTrace and/or SpotOn, Inc. and that any such agreements are strictly between MERCHANT and each individual company. MERCHANT must be approved by each company and each company may send its agreement to the address of MERCHANT indicated herein upon such approval. MERCHANT agrees to be bound by such company’s agreement. DISCOVER: By signing below, Merchant, CPAY and TSYS Merchant Solutions, LLC (“TMS”) agree to the terms of the TMS Discover Agreement and separately to the TMS American Express Agreement. TMS is not a party to the Merchant Transaction Processing Agreement.

CONTINUING PERSONAL GUARANTY PROVISION - PERSONAL GUARANTOR(S):

THIS general, absolute, and unconditional continuing Guaranty (“GUARANTY”) by the undersigned (collectively “GUARANTOR“ or “my” or “I” or “me”), is for the benefit of Central Payment Co., LLC/ or First National Bank of Omaha (“Collectively Guaranteed Parties”). For value received, and in consideration of the mutual undertakings contained in the Merchant Transaction Processing Agreement and allied agreements (“AGREEMENT”) between Guaranteed Parties and (“MERCHANT”) as set forth below, I absolutely and unconditionally guarantee the full performance of all MERCHANT’s obligations to Guaranteed Parties, together with all costs, expenses, and attorneys’ fees incurred by Guaranteed Parties in connection with any actions, inactions, or defaults of MERCHANT. I waive any right to require Guaranteed Parties to proceed against other entities or MERCHANT. There are no conditions attached to the enforcement of this GUARANTY. I authorize Guaranteed Parties, its agents or assigns to make from time to time any personal credit or other inquiries and agree to provide, at Guaranteed Parties’s request, financial statements and/or tax returns. I agree that this GUARANTY shall be governed and construed in accordance with the laws of the state of Nebraska, and that the courts of the state of Nebraska shall have and be vested with personal jurisdiction over me. This is a continuing GUARANTY and shall remain in effect until one hundred eighty (180) days after receipt by Guaranteed Parties of written notice by me terminating or modifying the same. The termination of the AGREEMENT or GUARANTY shall not release me from liability with respect to any obligations incurred before the effective date of termination. No termination of this GUARANTY shall be effected by any change in my legal status or any change in the relationship between MERCHANT and me. This GUARANTY shall bind and inure to the benefit of the personal representatives, heirs, administrators, successors and assigns of GUARANTOR and Guaranteed Parties.
Guarantor Signature
Select File
SIGN HERE
Date
Not Set
Printed Name of Signer
Title
BY THEIR EXECUTION BELOW THE UNDERSIGNED PARTIES AGREE TO ABIDE BY THE MERCHANT TRANSACTION PROCESSING AGREEMENT (THE “AGREEMENT”). THE AGREEMENT CONSISTS OF THE MERCHANT APPLICATION AND THE TERMS AND CONDITIONS (A SEPARATE ATTACHMENT HERETO), AND MERCHANT ACKNOWLEDGES IT HAS RECEIVED AND READ THE TERMS AND CONDITIONS AT THE TIME OF SIGNING. MERCHANT WARRANTS THAT THE INFORMATION PROVIDED ON THE MERCHANT APPLICATION IS COMPLETE AND ACCURATE. MERCHANT AUTHORIZES CPAY AND/OR BANK TO PROVIDE A COPY OF THIS MERCHANT APPLICATION TO ANY THIRD PARTY FOR THE SERVICES REQUESTED. MERCHANT, ITS SIGNING OFFICER, OWNER, PARTNER AND ANY PERSONAL GUARANTOR AUTHORIZE CPAY, BANK OR THEIR AGENTS OR ASSIGNS, TO MAKE FROM TIME TO TIME, BUSINESS OR PERSONAL CREDIT INQUIRIES AND OTHER INQUIRIES IN CONNECTION WITH THIS MERCHANT APPLICATION OR THE AGREEMENT. BY EXECUTING THIS MERCHANT APPLICATION, MERCHANT, ITS SIGNING OFFICER, OWNER, PARTNER AND ANY PERSONAL GUARANTOR ACKNOWLEDGE THAT CPAY AND/OR BANK HAS A LEGITIMATE BUSINESS NEED FOR THE INFORMATION CONTAINED IN ANY PERSONAL CREDIT REPORT THAT MAY BE OBTAINED IN CONNECTION WITH THIS MERCHANT APPLICATION OR THE AGREEMENT, AND THAT THIS APPLICATION IS A BUSINESS TRANSACTION THAT WAS INITIATED BY THE MERCHANT AND/OR ANY PERSONAL GUARANTOR IDENTIFIED ABOVE. IF APPLICABLE, MERCHANT AGREES BY ITS SIGNATURE BELOW TO THE AMERICAN EXPRESS OPTBLUE PROGRAM AGREEMENT. BANK IS NOT A PARTY TO THESE AGREEMENTS AND HAS NO OBLIGATION OR LIABILITY UNDER SUCH AGREEMENTS. IN WITNESS WHEREOF THE PARTIES HERETO HAVE CAUSED THIS AGREEMENT TO BE EXECUTED BY THEIR DULY AUTHORIZED REPRESENTATIVES EFFECTIVE ON THE DATE SIGNED OR APPROVED BY BANK.
Principal #1 Signature
Select File
SIGN HERE
Date
Not Set
Printed Name of Principal #1
Title
Principal #2 Signature
Select File
SIGN HERE
Date
Not Set
Printed Name of Principal #2
Title
Approved & Accepted By
Date
Not Set
Approved & Accepted By (“BANK”)
Date
Not Set
Central Payment, 2350 Kerner Blvd., Suite 300, San Rafael, CA 94901
First National Bank of Omaha,1620 Dodge Street, Omaha, NE 68197
COMPLIANCE FORM FOR ALL MERCHANTS
The merchant application and Terms & Conditions (@ www.cpay.com/conditions) attached hereto includes all terms of the service and/or agreement. If any other agreement was made between MERCHANT and Sales Representative, which such agreement shall not amend the Terms and Conditions in any way, it must be included in the “Special Instructions” area of the merchant agreement.
You understand the rates indicated in the Schedule of Fees section above, your Sales Representative proposed and understand the differences between the tiered pricing of Qualified, Mid-Qualified and Non-Qualified Fees.
INITIALS:
INITIAL HERE
INITIALS:
INITIAL HERE
BUSINESS
Void Check
Select File
Business card
Select File
ID card
Select File
Central Payment is a registered ISO/MSP of First National Bank of Omaha, Omaha, NEPage 3 of 3v0616ISOD