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

SN: 118214104867

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

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

Type

Install Date

Equipment ID

Status

Model

Purchase T.

PD Telephone

Sales Rep

Serial #

Tracking #

TID

Employee

Purchase Date

EPI: 2305970064

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 Advanced Dermatology Skin and Cancer Associates 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	Sep 23 2024		Charlotte Groff	Received equipment - cancelling account - submitted SR 61482174 in NPCrm for closing on Vantiv
2	Aug 30 2024		Mike Thomas	Emailed Kristi Wright return label for Valor equipment
3	Jan 03 2024		Charlotte Groff	added new contact Shelly Schefke and also added [email protected] to receive the daily batch reports from Valor. Charles Lock is no longer with merchant.
4	Nov 28 2023		Morgan Withee	Shelby new employee called in today and wanted a login to the VT. I created it for her.
5	Aug 09 2023	Aug 09 2023	Mike Thomas	TT Christie terminal not printing, had the paper inserted upside down. Corrected now printing.
6	Aug 01 2023			Valor Login for Admin: Username: clockAD , Password: Poplarpike7
7	Aug 01 2023			Charlotte and I downloaded a VL 100 terminal and VL 300 pin pad along with the VT. Mike will get this couriered out via express courier
8	Aug 01 2023			Entered in rate reduction with tonya to go active 3/1/23. attached rate reduction form in documents and merchant file
9	Aug 01 2023		Mike Thomas	User: Mike Thomas -> Notes: Ordered MP200L card reader and had it shipped direct to merchant
10	Aug 01 2023		Mike Thomas	User: Mike Thomas -> Notes: Changed open credit policy to no refunds per Emily K.
11	Aug 01 2023		Mike Thomas	User: Mike Thomas -> Notes: TT Dedan, says readers are working. TT Melissa says Rebecca has some billing issues. Tried to call her but no answer. Called 5 times.
12	Aug 01 2023		Mike Thomas	User: Mike Thomas -> Notes: Had 2 MP200L card reader delivered via courier SN: 315183000190 and 315183000191
13	Aug 01 2023			User: Pennye McAnulty -> Notes: Iterminal stopped working today.
14	Aug 01 2023			User: Kay Arpin -> Changed : MO Percent FROM 0 TO 10
15	Aug 01 2023			User: Kay Arpin -> Changed : Swipe Percent FROM 0 TO 90
16	Aug 01 2023			User: Kay Arpin -> Changed : AnnualVolume FROM 0 TO 720000
17	Aug 01 2023			User: Kay Arpin -> Changed : AverageTicket FROM 0.00 TO 95.00
18	Aug 01 2023			User: Pennye McAnulty -> Notes: The website has changed. The new website is merchantservices.chase.com, select sign in and then Online POS. Your same credentials should work.
19	Aug 01 2023		Mike Thomas	User: Mike Thomas -> Notes: Reset USA ePay password to hello789
20	Aug 01 2023		Mike Thomas	User: Mike Thomas -> Notes: Loaned 2 Pay saber jacks, and ordered them 2. TT Melissa

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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