Original Merchant number:
Rep Code:
Merchant Additional Location Form
Business Information
Merchant's DBA Name/Outlet Name:
Merchant's Legal Name:
Physical Street Address (No P.O. Box):
Legal Address:
City, State, Zip:
,
City, State, Zip:
,
DBA Phone:
(
)
-
ext.
Contact Name at this Address:
Fax:
(
)
Corp. Phone:
(
)
-
-
Email:
Fax:
(
)
ext.
Contact Name at this Address:
Customer Service Phone # (Required for MOTO and Internet merchants only):
(
)
-
-
Email:
Website Address (Required for Internet merchants):
Merchant Profile
Type of Ownership:
Sole Proprietor
Partnership
Corporation
LLC
Professional Assoc.
Tax Exempt Org (501C)
Other
Type of Goods or Services Sold:
SIC Code:
Years in business under current ownership:
Market Type:
Retail
Federal Tax ID#
Do you currently accept Visa/MasterCard/Discover?
YES
NO
Sales Profile (Must Equal 100%)
Supermarket
Restaurant
Lodging
Emerging Market
Public Sector
MO/TO
P-card
Auto Rental
Cash Advance
E-commerce
Other:
Does merchant accept transactions before the customer receives product or service?
YES
Card Swiped
%
Manually Keyed with Imprint
%
Mail Order/Telephone/Internet
%
Total =
100%
NO
% of sales in this category?
How long does customer wait before product is received?
% of cost that is prepayment?
Duration of extended service or benefit (in weeks):
Does merchant offer warranties, dues, subscriptions, memberships or other extended services?
YES
NO
Annual Visa/MC/Discover Sales: $
Average Ticket: $
Total Visa/MC/Discover Sales (multiple locations only): $
Credit/Debit Card Services and Fee Schedule*
Plan Type
New Existing
Existing Merchant No.
Discount Rate
Per Item
Additional Auth. Fees
N/A
N/A
VISA Credit
%
$
$
N/A
N/A
VISA Bus. Card
%
$
$
N/A
N/A
VISA Check
%
$
$
N/A
N/A
MasterCard Credit
%
$
$
N/A
N/A
MasterCard Bus. Card
%
$
$
N/A
N/A
Debit MasterCard
%
$
$
N/A
Discover Credit
%
$
$
N/A
Discover Bus. Card
%
$
$
N/A
Discover Check
%
$
$
American Express
%
$
$
Diners Club
%
$
$
Debit (other than Visa or MC)
%
$0.35
$
EBT
%
$
$
Other Fees:
*****Fees from the original application also apply to the additional location*****
$
Additional Location Fee
$
Other:
Daily Discount:
YES
NO
$
Virtual Site Survey Fee
$
Other:
Bank Information (Attach Voided Check or Bank Letter):
Routing Number
DDA/Checking Account #
Deposit
Discount
Chargebacks
Equipment
Supplies
Misc. Fees
Bank 1
Bank 2
Acceptance of Merchant Application and Terms & Conditions / Merchant Authorization
You have previously entered into a Card Services Agreement (the "Card Services Agreement"), including terms and conditions, with Global Payments Direct,
Inc. ("Global Direct") and the Member named below ("Member"). Member is a member of Visa, USA, Inc. ("Visa") and MasterCard International, Inc.
("MasterCard"); Global Direct is a registered independent sales organization of Visa, a member service provider of MasterCard and a registered acquirer for
Discover Financial Services, LLC. ("Discover"). Please sign below to signify your acknowledgement and agreement that the additional merchant location
identified above is subject to such Card Services Agreement. If this additional location is accepted for card services, Merchant agrees to comply with Card
Services Agreement as it may be modified or amended in the future. If you disagree with any of the above, do not sign this form.
IF MERCHANT SUBMITS A TRANSACTION TO GLOBAL DIRECT HEREUNDER FROM THIS ADDITIONAL MERCHANT LOCATION, MERCHANT
WILL BE DEEMED TO HAVE AGREED THAT THE ADDITIONAL MERCHANT LOCATION IS SUBJECT TO THE CARD SERVICES AGREEMENT.
By your signature below and on behalf of Merchant, you certify that all information provided in this additional location form is true and accurate and you
authorize Global Direct, and Global Direct on Member's behalf, to initiate debit entries to Merchant's checking account(s) in accordance with the Card
Services Agreement and order a consumer credit report on Merchant and you.
Merchant's Signature:
Name (printed):
Title:
Date:
X______________________________________
Signing for Global Payments Direct, Inc.:
Name (printed):
Title:
Date:
X______________________________________
Signing for Member:
Name (printed):
Name of Member (printed): Date:
X______________________________________
HSBC Bank USA, NA
1
Rev. 10/08 – GP-AL
Equipment / Terminal Applications
Process Method:
EDC
Touchtone
Platform:
East
Central
Imprinter:
Own
Purchase
Paper
Individual Pricing
Item
Quantity
Amount
Combination Pricing
# Payments
Amount
Terminal
$
$
Printer
$
$
Check Reader
$
$
PIN Pad
$
$
# Payments
Purchase Price per Unit: $
Purchase Quantity - Standard:
Purchase Quantity - Handheld:
Total Regular Plates Needed:
Total Amex Plates Needed:
Total Plastic Cards Needed:
Global to schedule download?
Global to train?
YES
Own / Reprogram
YES
NO
NO
Purchase
Lease
Rental
Special Instructions:
Terminal Type:
Pinpad Type:
Printer Type:
Check Reader:
Terminal Application / PC Software Type:
Primary Third Party:
Secondary Third Party:
Number of TIDs:
Term type:
Global PC Software:
If purchase, price: $
Product:
VAR Settlement:
Terminal
Host
Own
Purchase
# of payments:
Cardholder Data Storage Compliance
1. Are you going to use a POS terminal, software, or gateway application from Global Payments?
Yes
2. Are you using a "dial-up" terminal?
Yes
No
(If yes, go to Question #4 & select "No". If No, go to question #3.)
3. a) What third party software company/vendor did you purchase your POS Application from?
b) What is the name of the third party software?
Version #?
c) Do your transactions process through any other third parties, web hosting companies or gateways?
Yes
No
If yes, who is it?
(Please continue to Question #4)
4. a) Do you or your vendor receive, pass, transmit or store the full cardholder number, electronically?
Yes
No
b) If yes, where is card data stored?
Merchant
Third Party Only
Both Merchant & Third Party
b1.) Are you or your vendor PCI/DSS (Payment Card Industry/Data Security Standard) compliant?
Yes
b2.) What is the name of your Qualified Security Assessor?
b3.) Date of compliance:
Date of last scan:
5. Have you ever experienced an account data compromise?
Yes
No
If yes, when?
No
GAA Export Only
No
***** Card Association requirements dictate it is prohibited to store track data in any circumstance. Further, it is recommended that no merchant or a
merchant's third party vendor store cardholder data. If you or your vendor store data, you or your vendor are required to be PCI DSS compliant. Failure
to adhere to these requirements may result in fines or loss of card acceptance. *****
2
Merchant Initials: ____________
Rev. 10/08 – GP-AL