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 Douglas Fitwater 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: lindsaybank from Operations - Notes: I went by and Kim is out today, but I talked with Jenny; she said all is going well. I told her to let Kim know I came by; I saw Dr. Fitzwater and said hello- briefly.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
2	Aug 01 2023 12:00 AM			User: Lindsay Felker from - Notes: Phone line issue; had her move to another line and it worked fine; she is getting line checked.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
3	Aug 01 2023 12:00 AM			User: Lindsay Felker from - Notes: Signed Hayti Clinic today	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
4	Aug 01 2023 12:00 AM			User: Lindsay Felker from - Notes: Kim called and they want to set up a clinic in Hayti for processing. Meeting at 8am in Caruthersville.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
5	Aug 01 2023 12:00 AM			User: Lindsay Felker from - Notes: Lindsay went by to check on them yesterday; they were closed for lunch, so I didn't get to tt Kim; I will check next time I am over that way.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
6	Aug 01 2023 12:00 AM			User: First State Bank from Headquarters - Notes: Lindsay Felker went by and checked on Kim; all is going well with ImpactMD and c. card processing right now.	-	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 both c. card processing and ImpactMD; All is going well with c. cards, but had a question on Covenant insurance; said it would not let her put in dr. pin number; I called Dianna and talked to she and Emily; they called and talked to Kim; we had to add that provider; it had not been on the list we were provided for system set-up.	-	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 talked to Emily- she has been working with Amy at billing center; will contact Kim. I updated FSB today in the meeting with James Kaufman.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
9	Aug 01 2023 12:00 AM			User: First State Bank from Headquarters - Notes: Lindsay Felker e=mailed Emily to see where we are for updated status.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
10	Aug 01 2023 12:00 AM			User: First State Bank from Headquarters - Notes: Lindsay Felker- Emily said on conference call this morning she will be working to get them set up. She is loading all provider information for them.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
11	Aug 01 2023 12:00 AM			User: First State Bank from Headquarters - Notes: Lindsay Felker; Emily has sent me a form to send to them to fill out payor information; we want to test everything and make sure all goes well before set-up.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
12	Aug 01 2023 12:00 AM			User: First State Bank - Department: 1 - Notes: Signed up for ImpactMD today; faxing to office.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
13	Aug 01 2023 12:00 AM			User: First State Bank - Department: 1 - Notes:	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
14	Aug 01 2023 12:00 AM			User: First State Bank - Department: 1 - Notes: Received referral during meeting with Kathryn for them via Mike Abbott at the bank. They are interested in ImpactMD program as well. I went by and left a flyer and set appt to meet with Dr. Fitzwater on Tuesday, 12/11/07 at 8am. I let Kathryn know.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
15	Aug 01 2023 12:00 AM			User: First State Bank - Department: 1 - Notes: Went by and checked on them; Talked to Kim; all is going great! They love the machine vs. calling in for voice auth.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
16	Aug 01 2023 12:00 AM		Mike Thomas	User: Mike Thomas - Department: 5 - Notes: TT Lindsay (rep) download Hypercom T7PLUS TID# 480058817	-	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

Cancel