Pricing

Review and Submit

Merchant Information

Company Structure

Funding Information

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Program Pricing

V/M/D Processing Rate	3.25%
AMEX Processing Rate*	Included in Rate
Monthly Fee	$10.00

Chargeback Fee	$25.00
Retrieval Request Fee	$10.00
Voice Auth Fee	$0.95
NSF Fee	$25.00

Terms and Conditions may apply. For AMEX transactions an additional fee of 0.50% is applicable.*

Business Profile

DBA Name

What does this business do?

Website Url

First Name

Last Name

Email Address

Phone

Alternate Phone

Time Zone

Best Time to Contact

Address

Suite/Apt

City

State

Zip

Country

Questionnaire

How many locations?

Average Monthly Volume

Average transaction

Highest transaction

Legal Information

Legal Name

Legal Entity Type

Federal Tax Id

Business Start Date

Phone

Address

Suite/Apt

City

State

Zip

Country

Officer Information

First Name

Last Name

Phone

Title

Date of Birth

Social Security Number

Own part of the company?

Has a controlling position?

Address

Suite/Apt

City

State

Zip

Country

Bank Information

Bank Name

Name on Account

Routing Number

Account Number

Application Acceptance

Bank Disclosure*

Member Bank Information: Merrick Bank, 135 Crossways Park Drive North, Suite A100, Woodbury, NY 11797 • Phone (800) 328-9155 • Fax (516) 576-8741 Important Bank Responsibilities: 1.) Merrick Bank is the only entity approved to extend acceptance of Visa products directly to a Merchant. 2.) Merrick Bank is responsible for educating Merchants on pertinent Visa operating regulations with which Merchants must comply. 3.) Merrick Bank, not ANOVIA / NMI Payments, must hold, administer and control all reserve funds derived from settlement. 4.) Merrick Bank, not the ANOVIA / NMI Payments, must hold, administer and control settlement funds for the Merchant. 5.) Merrick Bank must be a principal (signer) to the Merchant Agreement. Merchant Information: Refer to Merchant Application Important Merchant Responsibilities: 1.) Complying with cardholder data security and storage requirements. 2.) Maintaining fraud and chargebacks below established thresholds. 3.) Reviewing and understanding the Merchant Agreement. 4.) Complying with Visa’s operating regulations. The responsibilities listed above do not supersede terms of the Merchant Agreement and are provided to ensure the Merchant understands some important obligations of each party and that the Visa Member - Merrick Bank - is the ultimate authority should the Merchant have any problems

By checking this box, you acknowledge that you have read and agree to the Bank Disclosure

Merchant Application and Agreement Acceptance*

IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING A NEW ACCOUNT: To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. What this means for you: When you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver’s license or other identifying documents.
MERCHANT APPLICATION AND AGREEMENT ACCEPTANCE (Capitalized terms not defined in the Acceptance section have the meaning set forth below in the Terms and Conditions section). By executing this Merchant Application on behalf of the merchant described above (“Merchant”), the undersigned individual(s) represent(s), warrant(s), and acknowledge(s) that: (1) All information contained in this Merchant Application (“Application”) is true, correct and complete as of the date of this Application, (ii) If the Merchant is a corporation, limited liability ompany, or partnership, the individual(s) executing this Application have the requisite legal power and authority to complete and submit this Application on behalf of the Merchant and to make and provide the acknowledgments, authorizations and agreements set forth herein on behalf of the Merchant and individually; (iii) The information contained in this Application is provided for the purpose of obtaining, or maintaining, a merchant account for the Merchant with the Member Bank (“BANK”) and BANK will rely on the information provided herein in its approved process and in settling the applicable Discount Rate, Approved Average Ticket, and Approved Monthly Card Volume; (iv) BANK is authorized to investigate, either through its own agents or through credit bureaus/agencies, the credit of the Merchant and each person listed on this Application; (v) BANK will determine all rates, fees and charges and notify Merchant of the approved fees and by Merchant’s submission and acceptance of Merchant’s first settled transaction, Merchant agrees to pay such approved fees; (vi) The Merchant Agreement will not take effect until Merchant has been approved by BANK and a merchant number has been issued to merchant; and (vii) The undersigned has received, read, understood the Merchant Agreement, which is incorporated herein by reference thereto, and agrees on The merchant on whose behalf this Application is being submitted acknowledges that if this Application is being submitted to Merrick Bank as the Member Bank, ANOVIA / NMI Payments may also be a party to this Merchant Agreement. In such case, Merchant acknowledges that ANOVIA / NMI Payments will rely on the representations and warranties set forth in this application for Merchant Agreement and unless otherwise specified or prohibited by Association of applicable law, ANOVIA / NMI Payments will have all the rights of BANK under this Application and Agreement.

By checking this box, you authorize the creation of your account

By checking this box, you acknowledge that you have read and agree to the Merchant Terms and Conditions

Business Profile

Tell us about your business

DBA Name*

Describe the Business Products or Services offered:*

Business Type*

Website Url?*

DBA CONTACT First Name*

DBA CONTACT Last Name*

DBA CONTACT Email Address*

DBA Phone #* ?

Alternate DBA Phone #

Business Location Time Zone*

Best Time to Contact*

DBA Business Address* ?

Suite/Apt

DBA City*

DBA State*

DBA Zip*

Transaction Expectations

Anticipated Card Acceptance Information

Monthly Volume?* ?

Highest Transaction?* ?

Average Transaction Size?* ?

PLEASE NOTE f/ AVG TICKET:
Average ticket over $1,000 requires document upload of last 3 months of bank statements and/or merchant processing statements

Swiped %* ?

Key Entered%* ?

MOTO %* ?

eCOMMERCE %* ?

Business to Business %* ?

Business to Consumer %* ?

PLEASE NOTE f/ CARD ENTRY METHOD USING LESS THAN 70% SWIPED OR KEYED CARD PRESENT
The following MOTO Questionnaire questions are required and will likely cause delays in Underwriting if not completed in full.

MOTO Q - Method of Marketing

MOTO Q - Order Processed By

MOTO Q - Card Transaction Entered By

Legal Information

Tell us how your business was formed

Legal Business Name*

Business Contact Phone #* ?

Business Email Address* ?

Legal Entity Type*

Federal Tax Identification Number (TIN)*

LLC State* ?

Business Start Date* ?

Tax Exempt*

PLEASE NOTE if YES to Tax Exempt
If applying under a Tax Exempt status, an upload of required 501(c)(3) or Tax Exempt documents is required

Legal Business Address*

Suite/Apt

Legal Business City*

Legal Business State*

Legal Business Zip*

Officer Information

Individual responsible for direction or management of business operations and authorized signer for the business.

First Name*

Last Name*

Phone*

Email*

Title*

Own part of the company?*

Has a controlling position?* ?

Ownership %*

SSN* ?

Date of Birth* ?

Please double check your social security number (SSN). If your SSN is incorrect, you may need to provide a scanned copy of your social security card to validate its accuracy.

Address*

Suite/Apt

City*

State*

Zip*

Beneficial Owner Agreement

Certification of Beneficial Owner(s)*

To help the government fight financial crime, Federal regulation requires certain financial institutions to obtain, verify, and record information about the beneficial owners of legal entity customers. Legal entities can be abused to disguise involvement in terrorist financing, money laundering, tax evasion, corruption, fraud, and other financial crimes. Requiring the disclosure of key individuals who own or control a legal entity (i.e., the beneficial owners) helps law enforcement investigate and prosecute these crimes. By signing below, I attest that I have accurately provided the name, address, date of birth and Social Security Number (SSN) for the following individuals (i.e. the beneficial owners): (i) Each individual, if any, who owns directly or indirectly, 25 percent or more of the equity interests of the legal entity customer (e.g., each natural person that owns 25 percent or more of the shares of a corporation); and (ii) An individual with significant responsibility for managing the legal entity customer (e.g., a Chief Executive Officer, Chief Financial Officer, Chief Operating Officer, Managing Member, General Partner, President, Vice President, or Treasurer). The number of individuals that satisfy this definition of “beneficial owner” may vary. Under section (i), depending on the factual circumstances, up to four individuals (but as few as zero) may need to be identified. Regardless of the number of individuals identified under section (i), you must provide the identifying information of one individual under section (ii). It is possible that in some circumstances the same individual might be identified under both sections (e.g., the President of Acme, Inc. who also holds a 30% equity interest). Thus, a completed form will contain the identifying information of at least one individual (under section (ii)), and up to five individuals (i.e., one individual under section (ii) and four 25 percent equity holders under section (i)). I, the undersigned, certify that all of the information furnished above with regard to information for each individual, if any, who directly or indirectly, through any contract, arrangement, understanding, relationship or otherwise, owns 25 percent or more of the equity interests of the legal entity listed above is complete and accurate.

By checking this box, you acknowledge that you have read and agree to the Certification of Beneficial Ownership

Back

Program Pricing

Review and Submit

Business Profile

Questionnaire

Legal Information

Officer Information

Bank Information

Application Acceptance

Merchant Information

Business Profile

Transaction Expectations

Company Structure

Legal Information

Officer Information

Officer Information 1

Beneficial Owner Agreement

Funding Information

Bank Checking Information

Document Upload

Document Upload