Merchants

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
		pre app

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 Tupelo Diesel Service 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	Mar 19 2025 10:06 PM			emailed to get business back I hope this message finds you well. I wanted to reach out as you were a valued customer of Impact PaySystem for several years, and we truly regret that we lost your business last year. Since then, we've introduced several new programs that we believe could better meet your needs. We would love the opportunity to earn your business back and help you achieve your goals. To that end, I would like to offer equipment at no cost, a rate reduction, or the possibility of eliminating fees altogether. Please let me know if you'd be open to a conversation so we can explore how our updated offerings can benefit your business. We look forward to the opportunity to work together again.	-	Dee Karawadra	Mar 19 2025 10:06 PM		Update Delete
2	Aug 01 2023 12:00 AM			Mike called to see how to cancel services and I gave him the support email and told him to send us an email with the owner's name MID and reasoning why.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
3	Aug 01 2023 12:00 AM		Mike Thomas	User: Mike Thomas -> Notes: TT Mike terminal having comms errors....did a certificate update download and tested....now working.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
4	Aug 01 2023 12:00 AM			User: Aimee Jones -> Notes: Needs to be PCI compliant.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
5	Aug 01 2023 12:00 AM			User: Kay Arpin -> Notes: Emailed Mr. Chunn registration instructions provided help desk number also	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
6	Aug 01 2023 12:00 AM			User: Aimee Jones -> Notes: They have been charged a non compliant fee. Transfer to Ms Kay to assist with compliance.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
7	Aug 01 2023 12:00 AM			User: Aimee Jones -> Notes: Terry Chun has a question about fees.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
8	Aug 01 2023 12:00 AM			User: Aimee Jones -> Notes: Terry Chunn called with a question about removing the sur charge from the receipt. I advised him that this was not possible.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
9	Aug 01 2023 12:00 AM			User: Aimee Jones -> Notes: Merchant is being charged for debit. He did not realize he would be charged for debit. He wants to be placed on the no fee debit program when it comes out.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
10	Aug 01 2023 12:00 AM			User: Aimee Jones -> Notes: Terry Chunn called to get set up to retrieve statements online.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
11	Aug 01 2023 12:00 AM		Mike Thomas	User: Mike Thomas -> Notes: TT Terry changed fon size from small to normal	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
12	Aug 01 2023 12:00 AM		Mike Thomas	User: Mike Thomas -> Notes: Talked to merchant, advised him they have to run this terminal (Desk3500) through IP. He does not have one. Will get one installed and call if he needs help.	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
13	Aug 01 2023 12:00 AM			User: Pennye McAnulty -> Changed : TO Percent FROM 0 TO 5	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
14	Aug 01 2023 12:00 AM			User: Pennye McAnulty -> Changed : Swipe Percent FROM 0 TO 95	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
15	Aug 01 2023 12:00 AM			User: Pennye McAnulty -> Changed : MonthlyVolume FROM 0.00 TO 62500	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
16	Aug 01 2023 12:00 AM			User: Pennye McAnulty -> Changed : AnnualVolume FROM 0 TO 6	-	Dee Karawadra	Jan 31 2024 01:39 PM		Update Delete
17	Aug 01 2023 12:00 AM			User: Pennye McAnulty -> Changed : AverageTicket FROM 0.00 TO 1500.00	-	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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