Transfirst/Merchant Card Processing 09TRANSFI RSf
Flr .! In Saan,M Electronic Payments
APPLICATION FOR MERCHANT CARD PROCESSING
STW Short Name: MONTANA Assoc #: 199292 Division: TF Government
Sales 'Rep Name SCOTT JARUMBO Sales Rep Code: Branch # (if applicable)
-Business Information
Legal Business Name (23 char max)
DBA Name (23 char max)
City of La Quinta, CA
City of La Quinta
Legal Address
DBA Address (Physical location, no PO Boxes)
78-495 Calls Tampico
78-49`.i Calls Tam ico
City State
ZIP
City State ZIP
La Quinta, CA 92253
La Quinta, CA 92253
Legal Phone Number
Legal FAX Number
DBA / Customer Service Phone Number DBA FAX Number
760-777-7150
760-777-7105
760-777-7150
Email address: (west@la- uinta-or
Website address: www.la- uinta.or
Preferred Address for:
Statements? ® Legal Address or
❑ DBA Address
Federal Tax ID (must ba 9 digits) Length Owned?
Chargebacks? ® Legal Address or
❑ DBA Address ❑ Dedicated FAX
953740431 27 Yrs
Contact Name: Louise West
Phone 760-777-7150
0 Mths
Any prior bankruptefes7 Business: ❑Yes ®No If Yes, Filing
Date? Personal: ❑Yes ❑No If Yes, Fling Date?
Type of Ownership:
Type of Business: El Retail El Restaurant El Lodging ® Service
❑ Business to Business % ❑ Internet % ElMOTO _%
Detailed business description (including description of Products or Services sold).
O Nen-Profit Corp
Provide separate pages if needed: Government Servicrs
MCC / SIC (for internal use only)
• - ..
NOTE: ONLY INCLUDE SOCIAL SECURrrY NUMBERS IF THE MERCHANT IS A PROPRIETORSHIP OR PARTNERSHIP AND PRINCIPAL IS AN OWNER OR GENERAL
PARTNER, OR IF HE/SHE IS A GUARANTOR OF THE MERCHANTS OBLIGATIONS UNDER THE MERCHANT AGREEMENT - TEXAS RESIDENTS: PROCESSOR'S PRIVACY
POLICY WITH RESPECTTO THE COLLECTION AND USE OF SOCIAL SECURITY NUMBERS CAN BE FOUND AT WW W.TRANSFIRST.COM.
Name of Principal and Title Percent Owned Social Security # Residential Address, City, State, Zip ResidentialPhone
Have you ever accepted credit cards before? Yes If yes, what is the processor's name? _ TransFirst
Please provide the most recent 3 months of credit card processingstatements. Are you currentlyundergoing a forensic investigation? ❑ Yes Z No
Number of locations? _ It you are affiliated with an existing account, please provide existing merchant ID#: _41399800819184
Do you bill your customers prior to goods being shipped? ❑ Ves No
U yes how many days? NA ❑ 0-2 days ❑ 3-30 days ❑ 31-60 days ❑ 60-90 days ❑ Over 90 days
What is your return and refund policy (Please be specific)
How do you advertise? (check all that apply) ❑Yellow pages ❑ Telemarketing ❑ Catalog ❑ Internet ❑ Word of mouth ❑ Publications ❑ Mass/Direct mail
❑ Other, please explain:
Terminal card swiped transactions
100
Terminal manually keyed (Card Present with Imprints)
Terminal manually keyed (Card Not Present / without
Imprints)
0 /
Touch Tone Capture/Dial Pay (Card Present with
Imprints)
NA
Touch Tone Capture/Dial Pay (Card Not Present I
without Imprints)
NA
Mail Order / Telephone Order (Card Not Present)
eCommerce Order (Card Not Present)
NA %
are
Do you snip your own w•cra9= ^-••••••
goods/products? It no, who Visa / MC/DISC Visa / MCIDISC
is yourthird-party fulfillment Transaction Sales
house? (Ticket)
(include contact name and Amount
phone number):
NA - Service Industry I 1_!i0_00 I 2$ 500.00
Cord Types Requested? Select
all that apply. ®All Visa/MC/DISC Credit Cards ❑All Visa/MC/DISC Debit Cards ❑ Visa/MC Debit Cards only
❑ Diners/Carte Blanche ❑ Visa/MC Credit Cards &Business Cards only El PIN Based Debit
El American Express (AMEX) El JCB
❑ F'urchasin Cards ❑ Cor orate Cards ❑ Fleet Cards ❑ Visa/MC Credit, Debit, & Business Cards only ❑ EBT Cards
List the names of each of your independent contractors or agents that will have access to cardholder data, including any third party order -taking serve;
(e.q , teleservices): (Provide separate pages if needed) NA
Bankin Information
Routing Number
Bank Account Number
Phone Number
ame of Financial Institution
[:-:-Wells
Shown on the bottom of check
Shown on the bottom of check
Faro I:
type
121000248 I:
of account to be used for ACH entries:
4159262482 II•
g acet ❑ Ssvin s acct ❑Bank acc
Checking 9
Please mark one box indicating the
n to initiateor transmit automatic debit and/or credit
"AUTHORIZATION FOR AUTOMATIC FUNub I Nenarcn p.wp � � �_ •��•�• •• --- •-
entries and/or check entries to the account identified above and in the provided voided check (if applicable) relating to the above account (••) for afl services corneri
under this Agreement. Said authority is granted to Merchant Bank's Processor and their agents.
Merchant initials
SCHEDULEFEE
Diecnunt Rate/Per tram Fee
Visa/MC/Discover Discount Rate
1.80%
Visa/MasterCard/Discover Per Item Fee _
$0.00
Visa/MC Debit Cards Only
0.00 %
Visa/MC Debit Cards Only Per Item Fee
$0.00
r Visa/MC CredidBusiness Cards Only
0.00%
1 Visa/MC Credit/Business Cards Only Per Item Fee _
$0.00
Visa/MC/Discover Authorization Fee
$0.26
1 _
selected — PIN eased
Voice Authorization/ARU
$.25
Mo thly Service Fee —
$6.00
Merchant ACH Fee
$0.00
Terminal Support Fee —
$0.00
Application Fee
$Waived
Minimum Discount Fee _
$0.00
ACH Return/Change Fee
$0.00
Reprogramming Fee —
$0.00
Char eback Fee
$20.00
TransLink Monthly Fee _
$0.00
Equipment Fee
$ .00
Breach Insurance
$6.95
All Visa/MasterCard/Discover interchange downgrades are passed thru. Cross border international transaction assessments/program support, MC network accessibrand
usage NABU , Visa US acquirer pmcess fee APR and card association base II and kilobyte tees may apply.—
AMEX/JCB Authorization Fee $0.00
_
American Express Discount Rate %
JCB Discount Rate
Retail: ❑ $0.10 Trans Fee + 0.30 % GNP Downgrade
Services, Wholesale & All Other: ❑ $0.15 Trans Fee
❑ Monthly Gross 0 Daily Gross Pay I
Diners/CarteBlance Discount Rate —1
$0.00
Est. AMEX Annual Volume: $
Est. AMEX Average Ticket —
$
AMEX Pay Frequency: 3-Day—
AMEX Fees disclosed in this section are billed by American Express —
❑ Transaction Central ❑ Transaction Central Plus
Peripheral Hardware
Monthly Gateway Fee
Item 1: —
Per Item Fee
Item 2: _
Ej
Per ACH Fee
Item 3: _
ACH Return Fee
SPOTCHFCK
Enrollment Fee:
Monthly processing fee
Non -Par Payor's Transaction Fee:
(Listings of par and non -par payors vary by state an(i
are updated by SPOTCHECK on a regular basis)
❑ Standard Verification
❑Standard Guaranty T
❑ Premium Verification' ❑ Premium Guaranty'
' Premium Packages include Electronic Check Conversion
Returned Item Fee: $3.00/1tem —
(Maximum approval limit $1,500)
Per Transaction Fee
Monthly Subscription Fee
Monthly Minimum Fee
Discount rate (Guaranty services only) —
Other Service:
Monthly Fee: $
❑ Gift Onl ❑ Giftcard Plus
Number of Locations: —
Cards acce ted at all locations? ❑ Yes ❑ No
Monthl Hostin Fee: —
Additional Location MonthlyHostingFee:
Transaction Fee:
(Includes Download, 25 4-color Pre -design cards w/sleeves. Card
❑ EZ Starter Kit per location
stand, counter top display, quick reference guide, decals and My
AccountTMl
❑ Standard Starter Kit per location
(Includes Download, 100 4-color Pre -design cards w%sleeves, card
stand, counter top display, quick reference guide, decals and My
AccountTM
❑ 'Custom Starter Kit per location
(Includes Download, card standcountertop display, quick reference
uide, decals and M Account _
❑ 'PLUS: Card Design and Plate
—
❑ 'Custom Card Order # of cards
Per Card Fee —
Additional Pre -Design Cards each
Card Sleeves each —
Other:
Download for Multi -Terminal Locations _
Intra-Pro ram Settlement/location/month:
Dail Weekly: Monthly: _
Per Re'ected Transactions
—
Merchant initials
Equipment .. ions
Equipment billed to: STW Manages Equipment Billing
I[em Deacription
Model #
Version or Serial
OTY
Code
Price'
Equipment Shipping : Ship to Legal Address
Terminal/So0ware
Verifone
Vx570
1
PIN
$
$
Welcome Kit sent by: TransFirsl
TerminaUSoflware
Welcome Kit shipped to:
$
Terminal/Software
❑ DBA Legal Acorn Other ❑ N/A
Enrollment
$
Merchant trained by: ® Colorado
PIN PaA
INTERNAL
INTERNAL
1
$
If other than selection above, STW Manages.
$
Equipment billing to be managed by Scott Jarumbo
ReadenCard
Swipe
m mar
$
Shi in
$
$0
Total
'Shipping and handling is collected by Sthrough a direct debit or credit card.
Codes: FUA =Free Use Addendum (Submit FUA addendum with this Application), MO =Merchant Owned, PN=Purchase New, PO =Purchased Via Other Source, PRF
= Purchased Refurbished, RTL = Rental / Lease, EE = Encryption Exchange, or STW = STW Provided.
80027 and
7For purposes of this 45-2659 and "Merchant Bantk' Is Columbus Bank rand Tlrust Company, loci at 1125 First Avenue, Columbus, GA, 31901rst Government LLC located at 371 Centennial Plavy, Louisville,1,,,(n be contacted at (800)
(706) 649-4900.
Agreement Signature: Each person signing below agrees that they have read and agree to the terms and conditions which have been provided to them and certifies that all
information provided in this application is true, correct and complete. Each person authorizes the Merchant Bank or any credit bureau or any credit reporting agency employed
by the Merchant Bank or any agent of the Merchant Bank, to make whatever inquiries the Merchant Bank deems appropriate to investigate, verify or research references,
statements or data obtained from Merchant for the purpose of this application, including requesting reports from consumer reporting agencies on persons signing below as an
owner or general partner of Merchant or as a Guarantor (if such person asks the Merchant Bank whether or not a consumer report was requested, the Merchant Bank will tell
such person, and if the Merchant Bank received a report, the Merchant Bank will give such person the name and address of the agency that furnished it). Each person also
authorizes the Merchant Bank to give information to others, including other creditors and credit reporting agencies, concerning the Merchant Bank's experience with
Merchant The Merchant Bank may request additional information if the Merchant Bank decides that it Is necessary. PLEASE CAREFULLY REVIEW THE TERMS AND
CONDITIONS OF VERSION 1.98 OF THE MERCHANT CARD PROCESSING AGREEMENT PROVIDED TO YBY REFERENCE.OU AND AVAILABLE AT
, IF APPLICABLE,
ASE ALSO CAREFULLY REVIEW
HE TERMS AND CONDITIONS OF VIER IONL79 8 OIF CH T ERCARD NOT PR SENHEREBYOTRATED ADD ADDENDUM AND VERSIONS 98 OF HE SPECIAL SERVICES ADDENDUM TO
THE MERCHANT CARD PROCESSING AGREEMENT PROVIDED TO YOU AND AVAILABLE AT W W W.TRANSFIRST.COM/REGULATIONS.HTML, WHICH ARE
BELOW,HEREBY INCORPORATED BY REFERENCE. BY SIGNING If) YOU ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD
D AGREE TO
TERMS AND CONDITIONS AND (I) YOU AGREE TO ACCEPT ELECTRONIC NOTIFICATION N
CATION OF ANY CHANGES TO THOSE TERMS ANDCONDIITIONS.THOSE
If Discover Network Card acceptance is selected above, Merchant hereby requests Discover Network Card acceptance be added to this Application. Note: Discover Network
Card processing services are provided by the Discover Network, Processor and their respective contractors. Merchant Bank does not provide such services and has no
responsibility or liability therefore. Merchant understands that the Terms and Conditions for Discover Network Card acceptance ('Discover Network Merchant Agreement and
LC for Merchant to accept the Discover Network Cards by Discover Financial
Operating Regulations') will be sent to Merchant upon approval by Discover Financial Services, Lant agrees to be bound by the Discover Network Merchant Services
Services, LLC. By accepting Discover Network Cards for the purchase of goods and/or services, Merch
ant Agreement and Operating Regulations. If American Express is selected above, then by signing below, I re resent that I have read and am authorized to sign and submit this
p
application on behalf of the entity above and all information I have provided herein is true, complete, and accurate. I authorize American Express Travel Related Services
Company, Inc ("Amercan Express") to verify the information in this application and receive and exchange information about me personally, including by requesting reports
from consumer reporting agencies. I authorize and direct American Express to inform me directly, or through the entity above, of reports about me that American Express has
requested from consumer reporting agencies. Such information will include the name and address of the agency furnishing the report. I understand that upon American
Express' approval of the entity indicated above to accept the American Express Card, the terms and conditions for American Express® Card Acceptance ("Terms and
Conditions') will be sent to such entity along with a Welcome Letter. By accepting the American Express Card for the purchase of goods and/or services, or otherwise
indicating its intention to be bound, the entity agrees to be bound by the Terms and Conditions. If selected above, Merchant agrees to be bound by and perform in accordance
with all the terms and conditions and provisions of the Check Services Agreement. Further, Merchant hereby requests Check Service acceptance be added to this Application.
Merchant understands that the Tens and Conditions for Check Service will be sent to Merchant upon approval by CrossCheck. If selected above, Merchant hereby requests
CrossCheck acceptance be added to this Application. Further, Merchant agrees to and accepts all terms and conditions as set forth by CrossCheck. If selected above,
Merchant hereby requests Tender Card Gift and Loyalty card acceptance be added to this Application. Further, Merchant agrees to and accepts all terms and conditions as
r Nt,Q11 ✓am
anm name role
zl Dare
Guarantor Signaiuu:
Date
Date
Accepted by Processor Date I Accepted by Merchant Bank
VISA DISCLOSURE PAGE
Name: Columbus Bank and Trust Company
Address: 1125 First Avenue
s, GA 31901
Phone:706-649-4900
1. A Visa Member is the only entity approved to extend acceptance of Visa products directly to a Merchant.
2. A 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 Name: City of La Quinta CA Merchant Phone: 760-777-7150
Merchant Address: 78-495 Calle Tampico, La Quinta, CA 92253
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. ComDly with Visa Operating Regulations.
The responsibilities listed above do not supersede 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.
Merchant Signature
Date
Merchant's Printed Name Title
Merchant initials