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<br /> <br />EQUIPMENT INFORMATION <br /> <br />PROVIDER CODESt: BAMS- BA Merchant SelViccs T ASQ= T ASQ Technology t BA MERCHANT SERVICES SHIPS EQUIPMENT ONLY IF BAMS IS <br />NOR Northern Leasin SOF- Sales Office BNK- Bonk MER- Merchonl SELECTED AS THE PROVIDER. <br />PA YMENT METHOD CODES: L= Lease P= Purchase R- Rental N- 90 Days. 0= ISO Days" V= VISA M= MaslerCanI <br />. 25% initial payment required; remaining balonce due in three equal monthly installments (Selecting Ibis option incun a 525.00 bandlinE fee.) <br />S% initial a enl r uired; remainin balonce due in five e ual monlhl inslallments Selectin Ibis 0 rion incun a 5100.00 handlin fee. <br /> <br />VSN= ViSBDel MAP= Mapp BUY= Buypass <br /> <br />RST= ReslaUTllDI FND= Fine Dining HOT= HOlel CA V= Cash Advance QSRa Quick Service RestaunIIll <br /> <br />AUTOCLOSE <br />TIME <br /> <br />T2 <br /> <br />02 <br />01 02 <br /> <br />lUes 8 PM <br /> <br />TI <br /> <br />eVes <br /> <br />CI TI [] T2 <br />[] TI [] T2 <br /> <br />BAMS <br /> <br />BAMS <br /> <br />If Merchant accepts and processes Internet transactions, I. Provide the name of Merchant's Internet service provider VERISIGN <br />2, Identi Gatewa: 0 BAMS [:J Other Gatewa : <br />THIS SECTION IS MANDATORY IF REQUESTING DEBIT CARD SERVICE THIS SECTION IS MANDATORY FOR PC TERMINAL SOFIWARE <br />WILL MERCHANT OFFER CASH BACK? SOFTWARE NAME PUBLISHED BY PLATFORM <br />DYES I!l NO AMOUNT 5 NA NA Doos <br />OPTIONAL PRINT LINES FOR THE ~CEIPT IN THE HEADER/FOO'J'ER <br /> <br />I!lWIN <br />C1MAC <br /> <br />LINE OF RECEIPT HEADER (up 10 20 cbarncI""') <br /> <br />LINE OF RECEIPT FOOTER (up to 20 characten) <br /> <br />2" LINE OF RECEIPT HEADER (up 10 20 charncI""') <br /> <br />2" LINE OF RECEIPT FOOTER (up to 20 charncten) <br /> <br />SHIPPING INFORMATION I!l Same as mailing address listed in Section 2. DShip to Ibe address lisled below. <br /> <br />CI Ship COD (If COD. shipping address MUST be soles office) <br /> <br />NO P O. BOXES - MUST BE PHYSICAL ADDRESS <br /> <br /> <br />CITY <br /> <br /> <br />PHONE; <br />STATE <br /> <br /> <br />ATTN: <br /> <br />. '6~ REFERRAL TO BPS. <br /> <br />The Merchant named below [] Agrees [] Disagrees that the Application submitted to BA Merchant ServicesIBank may be referred to Best Payment Solutions, Inc, <br />("BPS"), which is an affiliated company ofBA Merchant Services. IfBA Merchant ServicesIBank declines the Merchant's application for Merchant processing and if <br />the Merchant has marked the box above agreeing to the referral, then the Merchant's Application and all information gathered by BA Merchant ServicesIBank may be <br />provided to BPS for its consideration. BPS will notify the Merchant if it accepts the Application. BA Merchant ServicesIBank may refer this Application (excluding the <br />Business Credit Card Account Application) and provide copies of all related information, including financial information and information obtained from third parties, <br />and including credit reports to BPS, The Merchant agrees that BPS has all the rights under the Application to obtain and use any of the Merchant's financial, business <br />and credit information, whether obtained independently by BA Merchant ServicesIBank or BPS or provided by the Merchant. <br /> <br />Merchant Initials (Required): <br /> <br />GENERAL :pROv,isIONS CONTlNUEJ)'ON~NExt :PAGE <br /> <br /> <br />APPLICABLE ONLY IF MERCHANT ACCEPTS AMERICAN EXPRESS: I authorize American Express Travel Related Services Company, Inc (American <br />Express") to verify the information on this Application and to receive and exchange information about me, including, requesting reports from consumer reporting <br />agencies. If I ask American Express whether or not a conswner report was requested, American Express will tell me, and if American Express received a report, <br />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 <br />above to accept the American Express Card, the Terms and Conditions for American Express.Card Acceptance ("Terms and Conditions") will be sent to such business <br />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 <br />Conditions, <br /> <br />APPLICABLE ONLY IF MERCHANT ACCEPTS DISCOVER: By signing below, I represent that the information I have provided on this application is complete <br />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 <br />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 <br />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. <br /> <br />MERCHANT REPRESENTS THAT THE MERCHANT HAS CHOSEN FOR ITSELF ANY SERVICES, EQUIPMENT OR THIRD PARTY SELECTED IN <br />CONNECTION WITH THE AGREEMENTS AND MERCHANT'S DECISION WAS SOLELY BASED ON THE MERCHANT'S OWN CRITERIA AND <br />ANALYSIS, MERCHANT NOW AND FOREVER EXPRESSLY DISCLAIM ANY RELIANCE UPON PROMISES OR REPRESENTATIONS, UNLESS <br />SPECIFICALLY INCORPORATED HEREIN IN WRITING, MADE BY BA MERCHANT SERVICESIBANK, SALES REPRESENTATIVES OR OTHERS <br />RESPECTING THE FUNCTIONALITY, OPERABILITY, COMPATIBILITY, ETC. OF THE EQUIPMENT OR SERVICES. MERCHANT AGREES TO HOLD <br />RCHANT SERVICESIBANK HARMLESS FROM AND AGAINST ANY AND ALL CLAIMS, DAMAGES AND LIABILITIES ARISING OUT OF THE <br />LIGENCE OR WILLFUL MISCONDUCT, ACTS AND/OR OMISSIONS BY MERCHANT OR ANY THIRD PARTY ENGAGED BY MERCHANT, <br />UDING THE EMPLOYEES AND/OR AGENTS OF MERCHANT OR SUCH THIRD PARTY, <br /> <br />