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

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 THOMAS P. CHU, M.D. P.C. 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		Mike Thomas	User: Mike Thomas -> Notes: Requested cancel	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
2	Aug 01 2023 12:00 AM		Mike Thomas	User: Mike Thomas -> Notes: Downloaded VX520 will deliver to them today. Was just returned under warranty repair.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
3	Aug 01 2023 12:00 AM		Mike Thomas	User: Mike Thomas -> Notes: Took VX510DC to merchant location until VX520 is repaired under warranty	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
4	Aug 01 2023 12:00 AM			User: Christina Sullins -> Notes: VX520 says tamper and Mike said it will need replacing.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
5	Aug 01 2023 12:00 AM			User: Christina Sullins -> Notes: Sabrina called, she is getting a decline on a health savings card and was asking what to do.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
6	Aug 01 2023 12:00 AM			User: Christina Sullins -> Notes: Sabrina called asking about why the terminal wasn't taking the EMV cards, they have a VX520 that will need a partial download later for that encryption.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
7	Aug 01 2023 12:00 AM		Mike Thomas	User: Mike Thomas -> Notes: VX520 s/n 288-652-760	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
8	Aug 01 2023 12:00 AM		Mike Thomas	User: Mike Thomas -> Notes: Downloaded VX520, advised Joe. Sabrina pick up from office.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
9	Aug 01 2023 12:00 AM			User: Christina Sullins -> Notes: He also asked for EMV terminal pricing.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
10	Aug 01 2023 12:00 AM			User: Christina Sullins -> Notes: Joe asked if the terminal was EMV ready it is not, he may move them to Vantiv	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
11	Aug 01 2023 12:00 AM			User: Linda Billings from - Notes: Sabrina called. Forgot to batch on 4/17, just checking on auto/batch. Trans did settle.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
12	Aug 01 2023 12:00 AM			User: Linda Billings from - Notes: Sabrina called & I called back at ext 16. She is out so left brief message regarding sales higher than $140 causing Risk to question sales.	-	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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