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

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 Behavioral Medicine PLLC 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	Aug 01 2023	Dec 01 2023		Received Equipment back from merchant on 1/10/23 - cancelled on Elavon's side
2	Aug 01 2023		Mike Thomas	User: Mike Thomas -> Notes: TT Don instructed him how to batch manually and gave him the password 1 alpha alpha 66831. Terminal is auto batching he just wanted to know how.
3	Aug 01 2023		Mike Thomas	User: Mike Thomas -> Notes: Fed Ex shipment mishap downloaded VX520 SN: 263-070-992 TID# 23034285
4	Aug 01 2023		Kamal Oghad	User: Kamal Oghad -> Notes: Their terminal died so issued new VX520 DID: 23034285
5	Aug 01 2023			User: Charlotte Goff -> Notes: TT - Don - HIs ICT220 terminal would not power up and the green lights at the top just flashed. When he would unplug and plug back in the power to the terminal the power box would just flash. Called Elavon terminal support and they said he needed a new terminal. Sending him a VX520 replacement terminal today - $137 + tax + shipping
6	Aug 01 2023			User: Cheri Hansen -> Notes: Need DL EIN and voided check
7	Aug 01 2023			User: Pennye McAnulty -> Notes: Merchant terminal is not updating. Possibly needs new equipment. Transfer to Mike.
8	Aug 01 2023			User: Kay Arpin -> Changed : Swipe Percent FROM 0 TO 100
9	Aug 01 2023			User: Kay Arpin -> Changed : MonthlyVolume FROM 0.00 TO 3000
10	Aug 01 2023			User: Kay Arpin -> Changed : AnnualVolume FROM 0 TO 36000
11	Aug 01 2023			User: Kay Arpin -> Changed : AverageTicket FROM 0.00 TO 75.00
12	Aug 01 2023		Mike Thomas	User: Mike Thomas -> Notes: Downloaded and shipped iCT220 SN 2216054CT010330

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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