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

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

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 J Romo Inc 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	Sep 25 2023 12:00 AM			TT merchant. he moved to Square and thinks his balance is a wash because he claims we did not refund him in January for his Elavon fees. However, upon doing research on this I found on 2/6/23 we refunded him $113.87 for part of December and all of January's fees. He is going to call back once he does his own research to let me know what he wants to do about his account in collections. I instructed Mike to close his USA ePay account.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
2	Sep 25 2023 12:00 AM	Sep 25 2023	Mike Thomas	Cancelled USA ePay per Morgan	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
3	Sep 25 2023 12:00 AM		Charlotte Groff	As of 9/18/23 the merchant has an outstanding balance of $164.19 per Conrad	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
4	Sep 20 2023 12:00 AM		Morgan Withee	Merchant had ACH reject. Tried to reach out to him 5 times. Phone goes straight to voicemail. Conrad has closed out their account until they can pay for their ach reject	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
5	Aug 01 2023 12:00 AM			Called Jonathan back and told him we would be refunding part of December Elavon fees and all of January Elavon Fees. Let him know the refund should be added to one of his days of transactions next week and if he doesn't see it to call us back	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
6	Aug 01 2023 12:00 AM			Put in a request for refund totaling $113.87. December we refunded just the monthly fee and the statement fee totalling $16.44 as he did have some processing in that month and he was PCI non compliant. For January we refunded him $97.43 for all fees including non compliance since he is a long time merchant.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
7	Aug 01 2023 12:00 AM			SBC-Traditional-USAePay-IP	-	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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