Merchants

Submit API Set as Pre-App

Merchant ID*

Legal Name*

DBA Name*

Processor

Agent*

Split*

Is Override*

Password*

Status*

Product Type

Received Date*

Approved Date

Activation Date

Closed Date

Address

Address 2

City

ZIP

Country

State

Contact

Email(comma separated)

Phone

Phone 2

Cell

Fax

URL

DBA Same as Legal Address

Address

City

ZIP

Country

State

Mailing Address Same as DBA

Address

City

ZIP

Country

State

File here *	Download	Notes *	Status	Date	Action

Type*

Deployment Date*

EPI/TPN

Status*

Model*

Purchase T.*

Returned Date

Sales Rep

Serial #

Tracking #

TID

Employee

Purchase Date

Type*

Deployment Date

EPI/TPN

Status*

Model*

Purchase T.*

Returned Date

Sales Rep

Serial #

Tracking #

TID

Employee

Purchase Date

Send Email to Merchant Send Email to Sales rep Send Email to Employee Delete

Type*

Deployment Date

EPI/TPN

Status*

Model*

Purchase T.*

Returned Date

Sales Rep

Serial #

Tracking #

TID

Employee

Purchase Date

Send Email to Merchant Send Email to Sales rep Send Email to Employee Delete

Type*

Deployment Date

EPI/TPN

Status*

Model*

Purchase T.*

Returned Date

Sales Rep

Serial #

Tracking #

TID

Employee

Purchase Date

Send Email to Merchant Send Email to Sales rep Send Email to Employee Delete

Bank 1 Information

Bank Name

Account Name

Rounting Number

Account Number

Billing Type

Gross Settlement

Net Settlement

Bank 2 Information

Bank Name

Account Name

Rounting Number

Account Number

Overrides who receive partial commission on all of Hayden Pharmacy Accounts

Default Setup

Agent 1 Receives

%

on all Newly Inputted Accounts

Agent 2 Receives

%

on all Newly Inputted Accounts

Agent 3 Receives

%

on all Newly Inputted Accounts

Agent 4 Receives

%

on all Newly Inputted Accounts

Processor wise Setup

Select Processor *

Agent 1 Receives

%

on all Newly Inputted Accounts

Agent 2 Receives

%

on all Newly Inputted Accounts

Agent 3 Receives

%

on all Newly Inputted Accounts

Agent 4 Receives

%

on all Newly Inputted Accounts

Select Processor *

Agent 1 Receives

%

on all Newly Inputted Accounts

Agent 2 Receives

%

on all Newly Inputted Accounts

Agent 3 Receives

%

on all Newly Inputted Accounts

Agent 4 Receives

%

on all Newly Inputted Accounts

Merchant *

Month *

Year *

Merchant CMS

EIN/Federal Tax ID Type

MCC Code

EIN/Federal Tax ID #

State incorporated in

Business Start Date

Type of Legal Entity

Business Type

Sub Business Type

Types of Goods Sold

Primary Transaction Type

Card Swiped

%

Card Keyed In

%

Card Present

%

Card Not Present

%

Internet

%

Moto

%

B2B

%

B2C

%

Estimated Annual Sales Visa/MC/Discover/ AMEX Sales

Estimated Monthly Visa/MC/Discover/ AMEX Sales

Average Ticket

High Ticket

Persoanl Guarantor

Telephone Order

%

Discount Method

Refund Policy

30 Days

60 Days

Other

None

Print Refund Policy On Footer
(If Yes Input Message In Notes)

Yes

No

Location Type

Notes

Date

Reminder Date & Time

Employee

Notes

Sr. No.	Date	Reminder Date	Employee	Note	Documents	Created by	Updated at	Updated by	Action
1	Aug 01 2023 12:00 AM			User: Lindsay Felker from - Notes: Did check with SIGIS and called to let Mr. Hayden know that he is fine to utilize the healtchards with our system. They are mastercard backed.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
2	Aug 01 2023 12:00 AM			User: lindsaybank from Operations - Notes: Went by to check on them; card reader needed to be cleaned, so I did that while I was there; I also changed the time on the machine; They are happy; all is well.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
3	Aug 01 2023 12:00 AM			User: Lindsay Felker from - Notes: Linda rec'd a vm from Mr. Hayden; he rec'd some letter from a company about his eqpt. that it had to be software according to some pharmacy guideline; told him we can support 98% of software; he is happy with service and does not want to change, but wanted to see if I had heard of any other pharmacies in MO with this question; told him I had not and I will see what I can find out from local pharmacies.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
4	Aug 01 2023 12:00 AM			User: Lindsay Felker from - Notes: Went by and checked on them; all is going well; very happy.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
5	Aug 01 2023 12:00 AM			User: Lindsay Felker from - Notes: Called and needed to void out 2 transactions for $19.95- it was Ref#4 and Ref#5; we voided it and all is fixed!	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
6	Aug 01 2023 12:00 AM			User: Lindsay Felker from - Notes: Went by to check on them yesterday; all is going well; did have to change time on their machine.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
7	Aug 01 2023 12:00 AM			User: First State Bank from Headquarters - Notes: Lindsay Felker went by to check on them; all is going well!	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
8	Aug 01 2023 12:00 AM			User: First State Bank from Headquarters - Notes: Lindsay Felker went by to check on them; all is going well!	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
9	Aug 01 2023 12:00 AM			User: First State Bank - Department: 1 - Notes: Went by to check on their Discover; ran test transaction via number given to me by Paymentech; all working fine. Talked to Mr. Hayden- they are happy with everything.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
10	Aug 01 2023 12:00 AM			User: First State Bank - Department: 1 - Notes: Problems with Discover per Leslie; getting Invalid MID- I tested Visa and working fine; I talked with Paymentech and correct Discover MID is on file; Error message was 209; try transaction a 2nd time; they did; temporary card number issue; may not have had new card number.Seems to be a card problem with that particular card- Called and let Bridgette know it is a card number.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
11	Aug 01 2023 12:00 AM			User: First State Bank - Department: 1 - Notes: 11/29/07-Went in to check on them and they had me change time on their machine.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
12	Aug 01 2023 12:00 AM		Mike Thomas	User: Mike Thomas - Department: 5 - Notes: TT Lindsay (rep) download Tranz 330...TID# Z46477889, also ordering pin pad cable.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
13	Aug 01 2023 12:00 AM		Mike Thomas	User: Mike Thomas - Department: 5 - Notes: Ordered Pin Pad 1000se on PO# 2471 shipping to merchant NDA.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
14	Aug 01 2023 12:00 AM		Mike Thomas	User: Mike Thomas - Department: 5 - Notes: Mailed welcome kit.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete

Application Type

Discount

Business Type

MCC Code

Visa/MC/Discover Rate Category

Base/Qualified (%)

Mid Qualified (%)

Non Qualified (%)

Base Debit- Non Pin Debit(Sig Debit Rate) (%)

Rewards Discount (%)

Statement Fee

Card On File Fee

PCI Fee

Non PCI Compliance

Authorization Fee

Per Item Fee

EBT Fee

FNS/EBT Number

Pin Debit Item Fee

Pin Debit Discount

Amex Opt Blue Rate

Base/Qualified Rate (%)

Mid Qualified Rate (%)

Non Qualified Rate (%)

Program Cost Opt Blue (%)

Authorization Fee

Per Item Fee

Other Monthly Fee

Ancillary Fees

Batch Fee

Retrievel Fee

Chargeback Fee

ACH Change Fee

Voice Auth Fee

Gateway Monthly Fee

Setup Fee

Owner 1 Information

Officer/Owners Name

Title

Social Security

Form of ID

ID #

Issue Date

Expiration Date

State

DOB

Home Phone Number

% of Business Owned

Length of Ownership

Home Address

Home city

Home state

Home country

Home zip

Owner 1 Information

Officer/Owners Name *

Title

Social Security

Form of ID *

ID # *

Issue Date *

Expiration Date *

State *

DOB *

Home Phone Number

% of Business Owned

Length of Ownership

Home Address *

Home city *

Home state *

Home country

Home zip *

Software Or POS Integration Questions Only

POS Software Integration

Yes

No

Software Name & Version:

Pricing Provided

Statement Analysis

Quote

POS Software Publisher

Seasonal Flag

Seasonal Months

Deposit Time Frame

Deposit Type

Network ID

MP/AP Name

RP Name

Receipt Header Message

Receipt Footer Message

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