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
		var
		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

Type

Install Date

Equipment ID

Status

Model

Purchase T.

PD Telephone

Sales Rep

Serial #

Tracking #

TID

Employee

Purchase Date

Using bluetooth reader temporarily

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 Heale Medical 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			updated the banking information in NMI to Heale's new banking information. Also sent NMI Support email requesting that $140.00 of the return fees be moved over to Impact PaySystem as we negelected to inform the merchant that his fees were being returned. Request #594582 has been opened at NMI to move the $140 over to Impact's billing. Merchant will be responsible for paying the $35.40 (monthly fee + 1st reject fee + 0.40 for transactions)
2	Aug 01 2023			Still haven't heard from Amit so that I can conference him in with Vantiv to get his bank account changed. I called him and left a message for him today. I gave him the office number and asked him to call me so that we can get his banking info updated.
3	Aug 01 2023			Amit sent an email and needs to change his banking information. I have received the new voided check (uploaded to his folder on Gdrive), but I told him there is a process that WorldPay requires him to follow and that he would need to call the office so that we can conference him in with WorldPay. If he calls and I'm not available, transfer him to Morgan.
4	Aug 01 2023		Morgan Withee	User: Morgan Withee -> Notes: Will change off from $6 to $16 to add in swipe simple. Sent Aditya the rate change form just waiting to get it back to submit.
5	Aug 01 2023		Morgan Withee	User: Morgan Withee -> Notes: Added swipe simple for their covid testing. We placed the reader for free. They will return once they close out the Swipe Simple reader.
6	Aug 01 2023		Mike Thomas	User: Mike Thomas -> Notes: TT Amit Vantiv software support and NMI. Morgan corrected the processor info then we corrected the term ID to 001....now working
7	Aug 01 2023		Mike Thomas	User: Mike Thomas -> Notes: TT Amit having issues running transactions on live but can on demo...will call back when he gets developer with him tomorrow.
8	Aug 01 2023		Morgan Withee	User: Morgan Withee -> Notes: Set them up in NMI. Once ready we will link to their shopping cart
9	Aug 01 2023			User: Leah Faber -> Changed : B2C FROM 0 TO 100
10	Aug 01 2023			User: Leah Faber -> Changed : Internet Percent FROM 0 TO 100
11	Aug 01 2023			User: Leah Faber -> Changed : MonthlyVolume FROM 0.00 TO 4000.00
12	Aug 01 2023			User: Leah Faber -> Changed : AnnualVolume FROM 0 TO 50000.00
13	Aug 01 2023			User: Leah Faber -> Changed : AverageTicket FROM 0.00 TO 200.00

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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