Merchants

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Merchant ID

Legal Name

DBA Name

Processor

Agent

Split

Is Override

Password

Received Date

Approved Date

Activation Date

Closed Date

Product Type

Status

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
		signed app
		voided check

Type

Install Date

Equipment ID

Status

Model

Purchase T.

PD Telephone

Sales Rep

Serial #

Tracking #

TID

Employee

Purchase Date

Type

Install Date

Equipment ID

Status

Model

Purchase T.

PD Telephone

Sales Rep

Serial #

Tracking #

TID

Employee

Purchase Date

Send Email to Merchant Send Email to Sales rep Send Email to Employee

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 AFFORDABLE URGENT MEDICAL CARE 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 #

Type of Legal Entity

State incorporated in

Types of Goods Sold

Primary Transaction Type

Internet

%

Swipe

%

Keyed

%

Average Ticket

Telephone Order

%

Annual Volume

Business Start Date

High Ticket

Persoanl Guarantor

Monthly Volume

Discount Method

Refund Policy

30 Days

60 Days

Other

None

Date

Reminder Date & Time

Employee

Notes

Sr. No.	Date	Reminder Date	Employee	Note	Action
1	Apr 30 2024		Charlotte Groff	Cancelled account per Chad Patel. Submitted request in NPCrm to have WorldPay account closed - SR 60811922
2	Aug 01 2023		Mike Thomas	User: Mike Thomas -> Notes: Advised merchant that a $30.00 transaction did not go through
3	Aug 01 2023		Mike Thomas	User: Mike Thomas -> Notes: Canceled invoice merchant paid with a check.
4	Aug 01 2023		Mike Thomas	User: Mike Thomas -> Notes: Resent invoice that has not been paid
5	Aug 01 2023		Mike Thomas	User: Mike Thomas -> Notes: Replaced terminal VX520 with SN: 332-913-883 Sent invoice. Dial 8:00 pm auto settle
6	Aug 01 2023			User: Pennye McAnulty -> Notes: Spoke to Sunita about a transaction from today. It was cancelled and the customer is stating it is still showing on her card.
7	Aug 01 2023			User: Pennye McAnulty -> Notes: Spoke to Sunita she received a chargeback explained to her.
8	Aug 01 2023		Mike Thomas	User: Mike Thomas -> Notes: Went to merchant location to set up new terminal. Changed auto settle time to 8:00 pm and trained merchant on how to use terminal.
9	Aug 01 2023		Mike Thomas	User: Mike Thomas -> Notes: Download VX520 SN: 803-235-888
10	Aug 01 2023			User: Pennye McAnulty -> Notes: Spoke to Sunita and sent paperwork over to her.
11	Aug 01 2023			User: Pennye McAnulty -> Notes: left message regarding converting equipment.
12	Aug 01 2023			User: Kay Arpin -> Notes: 08-08-2018 left voice message regarding upgrading termnal
13	Aug 01 2023			User: Pennye McAnulty -> Notes: called Chase merchant had duplicate batch terminal needed to be cleared.
14	Aug 01 2023			User: Pennye McAnulty -> Notes: called Chase merchant had duplicate batch terminal needed to be cleared.
15	Aug 01 2023			User: Pennye McAnulty -> Notes: called Chase with merchant they could not batch the terminal. They were receiving duplicate batch error.
16	Aug 01 2023		Mike Thomas	User: Mike Thomas -> Notes: retry batch transfer Ran settlement...now working.

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

Y N

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

Y N

Home Address *

Home city *

Home state *

Home country

Home zip *

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