SERVICE PROVIDED TO. (please show additional locations separately) XXXX TO: (please leave blank if same as location address) Organized As: Corp__ LLC__ Sole Prop__ Partnership__Tax ID # ____________ DBA: _________________________________________ # Yrs in Business ____ DBA: ___________________________________ # Yrs in Business ____ Phone Number: ( ) ___________________ Fax # ( ) _______________ Phone Number: ( ) _________________ Fax # ( ) ____________ Address: __________________________________________________________ Address: _____________________________________________________ City/State/Zip: ______________________________________________________ City/State/Zip: ________________________________________________ Contact Name: ______________________________________________________ Contact Name:_________________________________________________ Email Address: _________________________________________ What Does This Business Sell? _______________________________ Retail ___ Wholesale ___ SERVICES : THIRD PARTY DATABASE VERIFICATION ONLY Subscriber shall provide secure transactions directly to SPS for authorization against any one or a combination of the Bank Validation Database, SPS Negative Database, APS Payday Lending Negative/Chargeback Database, Microbilt rVD, Microbilt rVD/Acct Validation, Telecheck Confidence Score, and/or Early Warning Services Positive / Negative Database. Please Select all that apply: SPS File APS File EWS File Microbilt rVD Microbilt w/Acct Valid Telecheck Risk Score Transaction Threshold Value > $ _______ $ ______ $ ______ $ ______ ____________________________________________________________________________________________________________________________________ Please Identify: Customer Present ____ or Customer Not Present ____ Manual Entry or Chk Scanner/Imager Model Please Identify: Host Interface ___ or WEB Interface ___ or POS Terminal (Make Model # ) Please Identify (if terminal) Card Processor Network ____________________ Gateway Provider: SERVICE FEES: Transaction Fee: SPS Access = $ ____ Basic Microbilt rVD Access = $ ____ Acct Validation Microbilt Access = $ ____ APS Access = $ ____ Early Warning CNP Access = $ ____ Telecheck Confidence Score = $ ____ Other Charges: Set-Up: $ ____ Monthly Flat Fee: $ ____ Annual Vetting Fee: $ ____ ACH ACCOUNT INFORMATION: (copy of business check is mandatory) Subscriber Financial Institution: ________________________________ City / State: ________________________________________________________
SERVICE PROVIDED TO. (please show additional locations separately) XXXX TO: (please leave blank if same as location address) Organized As: Corp LLC Sole Prop Partnership Tax ID # DBA: # Yrs in Business DBA: # Yrs in Business Phone Number: ( ) Fax # ( ) Phone Number: ( ) Fax # ( ) Address: _ Address: City/State/Zip: City/State/Zip: Contact Name: Contact Name: Email Address: What Does This Business Sell? Retail Wholesale ISO / BANK NETWORK: (Global, Paymentech,Vital,, etc. ) TERMINAL TYPE : Verifone Hypercom Thales Xxxxx XxxxXxxx PC Software (N)ew / (R)eprogram TERMINAL MODEL : ( Example: Omni 3750, PrimeTrex , T7+, Talento, 2085, 8320 ) Dial or IP CHECKREADER: Y N Type: Magtek CM3000 Ver CR600 Imager Model (N)ew / (R)eprogram SPS EQUIP / SOFTWARE ORDERED: BUY $ or RENT $ / mo SERVICES : (1) WARRANTY ONLY All Checks or Adverse Selection Est. Auth Vol / month $ Avg Chk $ Maximum Check Limit $ Claim Reimbursement By: ACH Check or (2) VERIFICATION ONLY (No Guarantee Provided) SERVICE FEES: Warranty Fee : (greater of % or $.50 per transaction) + $. per electronic inquiry Monthly Minimum: $ / Location (Guarantee) (except for the month of December whose warranty rate is increased by 0.18%) Verification Fee: (non-guarantee) $. per transaction Monthly Minimum: $ / Location (Verification) General Fees: $ Statement Fee Operator Assisted Call : $.95 Application / Set-Up: First Location $ + Each Add-On Location $ ACH ACCOUNT INFORMATION: (copy of business check is mandatory) Subscriber Financial Institution: City / State:
SERVICE PROVIDED TO. (please show additional locations separately) XXXX TO: (please leave blank if same as location address) Organized As: Corp LLC Sole Prop Partnership Tax ID # DBA: # Yrs in Business DBA: # Yrs in Business Phone Number: ( ) Fax # ( ) Phone Number: ( ) Fax # ( ) Address: Address: City/State/Zip: City/State/Zip: Contact Name: Contact Name: Email Address: What Does This Business Sell? Retail Wholesale SERVICES : VERIFICATION ONLY (No Guarantee Provided – No ACH Conversion) Subscriber shall provide secure transactions directly to SPS for authorization against any one or a combination of the Bank Validation Database, SPS Negative Database, APS Payday Lending Negative/Chargeback Database, NCN Negative Database, Microbilt rVD, Telecheck Confidence Scores, and/or Early Warning Services Positive / Negative Database. Please Select all that apply: SPS File APS File NCN File EWS File Accuity File Microbilt File Telecheck Confidence Threshold Value: $ $ $ $ $ $ $ Please Identify: Customer Present or Customer Not Present Manual Entry or Chk Scanner/Imager Model Please Identify: Host Interface or WEB Interface or POS Terminal (Make Model # ) Please Identify (if terminal) Card Processor Network Transaction Delivery: Dial-Up or IP SERVICE FEES: Transaction Fee: SPS Access = $ NCN Access = $ rVD Access = $ Telecheck Access = $ APS Access = $ EWS Access = $ Accuity Access $ or “All” Bundled Rate = $ Other Charges: Initital Set-Up: $ Monthly Fee: $ Annual Fee: $ ACH ACCOUNT INFORMATION: (copy of business check is mandatory) Subscriber Financial Institution: City / State: Subscriber ABA Transit Number: Subscriber Account Number: On the 10th of each month (or the preceding Friday if the 10th is a Saturday / Sunday or bank holiday Monday) Subscriber authorizes its Financial Institution to charge Subscriber’s account and pay SPS by electronic funds transfer the total amount due in Subscriber’s monthly invoice. Subscriber agrees that SPS invoices and reports shall only be delivered to Subscriber via email or an SPS provided online, WEB interface. Subscriber agrees that this electronic debit authorization shall remain in effect until and unless such is revoked in writing upon the mutual consent of the parties.
