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
		Pre app too large to upload
		Signed app too large to upload

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 Pass Road Food Mart LLC. 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	Feb 20 2025		Charlotte Groff	Received confrimation from PCS that the bank account has been changed and that everything beginning with today's batch will go to the new account. They also notified Finance so that any held ACHs that occurred on the old closed bank account will be posted to the new bank account.
2	Feb 19 2025		Charlotte Groff	Taha sent the signed Account Change form and the new voided check back so I submitted it to PCS to get the banking info updated. Case number 04403535. I updated banking info in our system.
3	Feb 19 2025		Charlotte Groff	Merchant called while I was at lunch and told Alex that he had sent the new bank info back to me, but I have not received it in my email. I returned the merchant's call on the cell number we have for him and it went straight to voice mail so I left a message.
4	Feb 18 2025		Charlotte Groff	Merchant called and said that his bank account has been hacked and needed to change his bank account. Sent him the form to fill out and sign and told him to send the form back to me. He has already cancelled his old bank account so the funds from the last few days should be returned to PaySafe.
5	Dec 04 2023		Morgan Withee	Merchant wants to purchase terminal. I sent them an invoice for this.
6	Dec 04 2023		Charlotte Groff	Devin - store manager - called and asked if it was us that made the Verifone VX520 start working over the weekend. I told him no that that terminal is still programmed for the old owner account. Talked to him about a Valor 100 to replace the VX520. They agreed to purchase the terminal for $225 + tax + shipping. Morgan sent invoice and I've requested the Var from PCS (ticket # 5123157). This terminal will need Credit, Debit and EBT programmed on it.
7	Nov 21 2023			PCS Direct Traditional Pricing Gilbarco Passport

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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