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<br />~-- <br /> <br />I 3. BUSINESS CERTIFICATION <br /> <br />CERTIFICATION OF MERCHANT'S CARD PROCESSING ACTIVITY <br /> <br />L~ 0 I % Card Presented 5 0 2 5 <br />- LL~_J~I % Card Swiped I I I <br />+ L~tJll % Card Not Present <br />MUST EQUALIOO% TOTAL I 1 I I %MOrrO(Calalog) 12 I 51 <br /> <br /> <br />% Hand Eotered (Manually Keyed) <br />% Internet <br /> <br />Anticipated Annual Volume of Merchant's MCNS Gifl Card Sales: <br />sO <br />Has Merchant previously processed MeNS? GJYES 0 NO <br />If yes, name of previous processor: WELLS FARGO <br /> <br />Is Merchant's business seasonal? DYES [!]NO <br />If yes, list inactive months: <br /> <br />I <br /> <br />Last 3 months consecutive statements are attached? l!lYES DNa <br /> <br />o Current l!J Previous BANKCARD PROCESSOR NAME <br /> <br />WELLS FARGO <br /> <br />If cwrenllprevious processor is Bank of America, list MerchantlD II <br /> <br />1-' 1-' I~~----.J~ 1-' I-'~-'~~ <br /> <br />Average MCNS Ticket - Primary Location <br /> <br />Projected monthly VisalMC Sala: <br /> <br />Total Annulll Volu_ - AU Locations <br /> <br />s <br /> <br />207 <br /> <br />s <br /> <br />315,225 <br /> <br />s <br /> <br />8,000,000 <br /> <br />Projected monthly check sala <br /> <br />Occasional Higher Tickeb To: <br /> <br />Tolal Projected Monthly SIlIa from AU Payment Types: <br /> <br />S <br />Is a fulfillment house used? <br />If yes, I ist name: <br />Address: <br />City. <br />Tele hone: <br /> <br />o <br />DYes GJNo <br /> <br />s <br /> <br />o <br /> <br />s <br /> <br />413,081 <br /> <br /> <br />State : <br /> <br />Zip: <br /> <br />When is the Merchant's customer billed? (Check one) <br />o On order <br />o On inventory verification <br />o On shipment <br /> <br />Where is the Merchant's invento housed? <br />Merchant elects acceptance of the following Card types (additional Card types listed on the Fee Schedule): <br />o MasterCard credit cards only 0 MasterCard off-line debit cards only rn All MasterCard cards <br />o Visa credit cards onl 0 Visa off-line debit cards onl [!] All Visa cards <br />TRADE REFERENCE <br />TRADE REFERENCE NA CONTACTNAMElPHONEII NA <br /> <br />STREET ADDRESS NA <br />STATE <br /> <br />CITY NA <br /> <br />ZIP <br /> <br />ACCOUNT NUMBER <br /> <br />YEARS/MONTIlS IN BUSINESS <br />12 <br />HOW LONG AT TIilS LOCATION <br />12 <br /> <br /> <br />CERTIFICATION OF MERCHANT'S BUSINESS <br />YEARS UNDER CURRENT OWNERSHIP BUSINESS TYPE <br />12 GOVERNMENT ENTITY <br />No refund 0 Rcfimd in 30 d'!Xs or less <br />o Merchandise exchange only ~ Other AS NEEDED BASIS <br />BUSINESS ENVIRONMENT (Check AU That Apply) <br />DKiosk [l Seminar <br />[lInHomc DMOrro <br />[J Trade Showl Flea Marl<et [l JoblSennce Site <br />D Business to Business mOther TELEPHONE <br /> <br /> <br />FORM OF OWNERSHIP (Mandatory) <br />DSole Proprietor [lPartncrship ~Govmuncnt <br />DLimited Parmenhip 0 Assoc. I Estate. I Trusb D Medical or Legal COI]I, <br />[JTax Exempt Organization [J International Organization [J Limited Liability Company <br />[lColJlOration (Privatcly traded) [JCOlJlOlllbOD (Publicly traded) Symhol: <br /> <br />DStorefront <br />~Office <br /> <br /> <br /> <br /> <br /> <br />MERCtIANT TYPE <br /> <br />TYPE: 1 1= Retail 2= Restaurant 3= IntemetlWireless 4= MOrrO 5= Supermarket 6= Car Renlal 7= Small TicketlQSR 8= Lodging. 9= Other. <br />· If Merchant is a Lodging Merchant, does thc Merchant utilize check in/chcck out? [lYes DNo If MOTO, provide Customer Service phone number: <br /> <br />TERMINAL TELEPHONE LINE & MERCHANT TRAINING INFORMATION <br /> <br /> <br />SA MERCIIAN1"SER. <br /> <br /> <br />TYPE OF SERVICE (TERMlNAUPC) <br /> <br />ROLL OVER LINES? <br />