Merchants

Submit to SBC 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
		signed app
		var
		pre app
		signed app
		business verification
		DL

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

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 Marion County Treatment Center 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	Feb 27 2024 10:56 AM		Charlotte Groff	Received equipment and signed cancellation request back from merchant. Submitted request to SBC. Cancelling account.	-	Charlotte Groff	Feb 27 2024 04:58 PM		Update Delete
2	Feb 06 2024 03:26 PM		Charlotte Groff	Kim Wilson texted me and asked me to send her a cancellation form for this merchant. I emailed it to Kim's Impact email address and let her know that we can not cancel the account until we receive the equipment back.	-	Dee Karawadra	Feb 06 2024 09:27 PM		Update Delete
3	Oct 31 2023 12:00 AM	Oct 31 2023	Mike Thomas	TT Renee, she is not getting an internet connection, she will have her IT person check the internet and call us back.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
4	Aug 01 2023 12:00 AM			shipped replacement S80	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
5	Aug 01 2023 12:00 AM			Will not read chip cards, requested new VAR to replace	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
6	Aug 01 2023 12:00 AM			TT Merchant terminal not communicating with internet. Tried resetting the terminal but didn't work. Merchant is going to reset the router and call back if they need further assistance	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
7	Aug 01 2023 12:00 AM			TT Sarah disabled debit on PAX S80	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
8	Aug 01 2023 12:00 AM			Sarah Cook from Marion County Treatment Center called in at 10:50am returning a call from Mike, said he was trying to update her machine. Mike was on a call so I took a message and passed it to Mike as soon as he got off the phone with another customer.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
9	Aug 01 2023 12:00 AM		Mike Thomas	User: Mike Thomas -> Notes: TT Sarah need totals from Saturday 2/26/22	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
10	Aug 01 2023 12:00 AM		Mike Thomas	User: Mike Thomas -> Notes: TT Sarah had a question concerning debit....advised her to run everything as credit because of iBUXX	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
11	Aug 01 2023 12:00 AM		Mike Thomas	User: Mike Thomas -> Notes: TT Sarah walked her through setting up terminal and walked her through a transaction...all working. She also wanted to know how to settle if they wanted to settle early...gave her instructions	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
12	Aug 01 2023 12:00 AM		Mike Thomas	User: Mike Thomas -> Notes: Downloaded PAX S80 shipped FedEx ground tracking number 774498643022	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
13	Aug 01 2023 12:00 AM			User: Charlotte Goff -> Notes: SBC - IBUXX; 3.95%; Pax s80; IP; Batch: 6:00pm	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
14	Aug 01 2023 12:00 AM			User: Charlotte Goff -> Changed : Internet Percent FROM 0 TO 2	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
15	Aug 01 2023 12:00 AM			User: Charlotte Goff -> Changed : Swipe Percent FROM 0 TO 98	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
16	Aug 01 2023 12:00 AM			User: Charlotte Goff -> Changed : MonthlyVolume FROM 0.00 TO 38000	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
17	Aug 01 2023 12:00 AM			User: Charlotte Goff -> Changed : AnnualVolume FROM 0 TO 450000	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
18	Aug 01 2023 12:00 AM			User: Charlotte Goff -> Changed : AverageTicket FROM 0.00 TO 16.00	-	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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