Fax Cover Sheet and Application Checklist. Checklist for Submitting an Authorize.Net Payment Gateway and Optional Merchant Account Set-up Form

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Fax Cover Sheet and Application Checklist Attention: From: Company: Authorize.Net Date: Fax Number: (801) Total No. of Pages (including cover): Reseller Name: Web Spinners, Llc. Reseller ID: 1517
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Fax Cover Sheet and Application Checklist Attention: From: Company: Authorize.Net Date: Fax Number: (801) Total No. of Pages (including cover): Reseller Name: Web Spinners, Llc. Reseller ID: 1517 Checklist for Submitting an Authorize.Net Payment Gateway and Optional Merchant Account Set-up Form If You Have an Existing Merchant Account: Complete and fax the following pages: Payment Gateway and Optional Merchant Account Setup Form Authorization for Single Direct Payment Appendix A: Merchant Account Configuration Form Authorize.Net Payment Gateway Fees: One-Time Set up Fee: $149 Monthly Gateway Fee: $20 Per-Transaction Fee $0.10 If You Need a Merchant Account: Complete and fax the following pages: Payment Gateway and Optional Merchant Account Setup Form Authorization for Single Direct Payment Appendix B: Internet Merchant Account Setup Form Authorize.Net has several merchant account partners that can help you obtain a merchant account. Actual rates and fees will be presented to you before you commit to a merchant account from one of our partners. Estimated Merchant Account Fees (In addition to the Authorize.Net Payment Gateway Fees): One-Time Setup Fee: $0 Monthly Service/Statement Fee: $9.95 Transaction Fee: $0.25 VISA/MasterCard Qualified Discount Rate: 2.39% Monthly Processing Minimum Fee *: $25.00 For information regarding large volume pricing, please call (866) *Monthly Processing Minimum Fee: There is a $25.00 Monthly Processing Minimum Fee for every merchant account. This is the minimum amount you must pay each month for your Visa/MasterCard processing. However, this fee is only billed when it is not exceeded by your monthly transaction fees. Example: If your rate is 2.39% and you sell $1200 in goods or services during one month, your total Visa/MasterCard processing fees would be $28.68 ($1200 x 2.39% = $28.68). This amount is greater than the $25.00 Monthly Processing Minimum Fee, so you would not be billed the minimum fee for the month. PAYMENT GATEWAY SETUP FORM ATTENTION: Sales Department RESELLER NAME: Web Spinners, Llc. ID: 1517 Instructions: Please fax the completed setup form to If you have any questions about this form, please call our Sales Department at (866) or by at STEP 1: COMPANY INFORMATION Company Name: Company Officer / Owner / Principal Name: Title: Tax ID or Social Security Number: Company Address (No P.O. Boxes): City: State: ZIP Code: Company Phone Number: Company Fax Number: Address: Business Type (circle one): Corporation Non-Profit Corporation LLC Sole Proprietorship LLP Market Type (circle one): Card Not Present (CNP)/E-commerce Mail Order/Telephone Order (MOTO) Card Present (CP)/Retail Software Used to Submit Transactions to Authorize.Net: Detailed Description of Products or Services Sold: STEP 2: PAYMENT AND ACCOUNT INFORMATION IMPORTANT: You must also complete the AUTHORIZATION FOR SINGLE DIRECT PAYMENT form on Page 2 FEES: Non-Refundable Setup Fee: $149 Monthly Gateway Fee: $20 Per-Transaction Fee: $0.10 Monthly Gateway & Per-Transaction Fee. Authorize.Net shall charge Company a Monthly Gateway Fee and Per-Transaction Fee in the amounts provided above. Billing shall commence upon the execution date of this Account Setup Form and such fees will be billed automatically on a monthly basis to the bank account provided on page 2. Non-Refundable Setup Fee: Company agrees to pay to Authorize.Net a one-time non-refundable fee in the amount written above for the setup of Company s payment gateway account and access to the Authorize.Net Services (the Setup Fee ), pursuant to the attached Authorization for Single Direct Payment (ACH Debit) form. Company agrees that by signing below: (i) it permits Authorize.Net to share any and all information contained herein with its service partners for the purpose of establishing a Merchant Account, if applicable: and (ii) further agrees to be bound by the terms and conditions set forth in the Authorize.Net Service Agreement, incorporated herein by reference, which can be found at: Company s signature confirms acceptance of the Setup, Monthly, and Per-Transaction fees. Signature: Date: Print Name: Print Title: Optional Services: Automated Recurring Billing (ARB) Setup Fee - $0.00 Monthly Fee - $10.00 Add ARB to account (please circle) Yes No Fraud Detection Suite (FDS) Setup Fee - $0.00 Monthly Fee - $5.00 Add FDS to account (please circle) Yes No 1 Authorize.Net Corp. 915 South 500 East, Suite 200 American Fork, Utah (801) AUTHORIZATION FOR SINGLE DIRECT PAYMENT (ACH DEBIT) RE: ACH Authorization for one-time Setup Fee in consideration of the payment gateway account set-up services provided to Company by Authorize.Net Corp. (Authorize.Net). The Company listed below hereby authorizes Authorize.Net to initiate a debit entry to Company s checking account at the depository financial institution named below, hereinafter called Depository, and to debit the same to such account for the amount listed below. Company acknowledges that the origination of ACH transactions to Company s account must comply with the provisions of U.S. law. PAYMENT AND ACCOUNT INFORMATION Bank Name: Account Type (circle one): Checking Savings Branch City: Branch State: ZIP Code: Routing Number (9 digits): Account Number: Amount: $ The amount of the Non-Refundable Setup Fee set forth on the Payment Gateway Account Setup Form. Effective Date: The date that Authorize.Net Corp. receives Company s completed Payment Gateway Account Setup Form and Authorization for Single Direct Payment (ACH Debit). This authorization is to remain in full force and effect for this transaction only, or until such time that my indebtedness to Authorize.Net for the amount listed above is fully satisfied. The specific debit to Company s account authorized herein may only post on or after the Effective Date listed above, and in no event may the debit transaction post to Company s account prior to said date. Company may only revoke this authorization by contacting Authorize.Net directly at the address and phone number listed above, and only in the case that it cancels the set-up services provided by Authorize.Net on the date that Authorize.Net received Company s completed Payment Gateway Account Set-Up Form and Authorization for Single Direct Payment (ACH Debit). Company further agrees to be bound by the terms and conditions set forth in the current Authorize.Net Service Agreement, incorporated herein by reference, which can be found at: Print Company Name: Date Print Corporate Employee Name: Signature: Please fax a voided check along with your completed form. This will be used to verify the bank account information provided. STEP 3: MERCHANT ACCOUNT INFORMATION What is a Merchant Account? A merchant account is a type of account established with a bank or merchant service provider for the settlement of credit card transactions. Any merchant who wants to accept credit card transactions must establish a merchant account. Internet merchants need a Card Not Present merchant account. If you already have a merchant account, complete Appendix A. You DO NOT need to complete Appendix B. If you need a merchant account, complete Appendix B. You DO NOT need to complete Appendix A. If you need help determining if you already have a merchant account or have any other questions, please call at 2 APPENDIX A: MERCHANT ACCOUNT CONFIGURATION FORM IMPORTANT: Appendix A must be completed by Merchants with active Merchant Accounts. If you DO NOT yet have a Merchant Account, you need to complete Appendix B. STEP 1: CREDIT CARD TYPES THAT YOUR MERCHANT ACCOUNT IS CURRENTLY CONFIGURED TO ACCEPT Accepted Cards (circle all that apply): Visa/MasterCard American Express Discover Diner s Club JCB Enroute STEP 2: MERCHANT ACCOUNT PROCESSOR CONFIGURATION INFORMATION Instructions: Please provide the requested information for the processor that is associated with your Merchant Account. You only need to provide information for ONE processor. If you do not know this information, please contact at, who would be happy to assist you. First Data Corporation (FDC) Nashville Platform Merchant ID (MID) (7-11 digits): Terminal ID (TID) (7-11 digits): First Data Corporation (FDC) Omaha Platform Merchant ID (MID) (15 or 16 digits): Nova Bank # / Term BIN (6 digits): Terminal ID (TID) (16 digits): Vital Acquirer BIN (6 digits): Agent Bank # (6 digits): Agent Chain # (6 digits): Category Code (4 digits): Terminal ID (TID) (4 digits): Store # (4 digits): Merchant # (12 digits): Global Acquirer Inst. ID (Bank ID) (6 digits): Merchant ID (MID) (Usually 16 digits): Paymentech Client (4 digits): Merchant # (Gensar #) (12 digits): Terminal # (TID) (3 digits): Concord EFS BuyPass / Terminal # (TID) (6 digits): Merchant ID (MID) (2 digits): CardSystems Solutions Acquirer BIN (6 digits): Terminal ID (TID) (10 digits): Lynk Systems Acquirer BIN (6 digits): Store # (4 digits): Terminal # (TID) (4 digits): Merchant # (12 digits): Market Type (circle one): E-Commerce MOTO Retail Merchant Category Code (4 digits): 1 APPENDIX B: INTERNET MERCHANT ACCOUNT SETUP FORM IMPORTANT: Appendix B must be completed by Merchants in need of an Internet Merchant Account. If you ALREADY HAVE an Internet Merchant Account, you do not need to complete Appendix B. Please verify that you have completed Appendix A. STEP 1: MERCHANT ACCOUNT SETUP Instructions: If you need an Internet / Card Not Present Merchant Account, you must complete this setup form and fax it to your Authorize.Net Sales Representative. Authorize.Net has relationships with leading companies in the payment processing industry to help you obtain an Internet / Card Not Present Merchant Account. Authorize.Net will review the information provided and match your application to the Merchant Account provider best suited to serve your particular business. Please note that this is a pre-application. There may be additional signatures and/or information requested by the account provider underwriting your Merchant Account application. Authorize.Net will contact you with your Login ID and Password. Once your Merchant Account is approved Authorize.Net will also work with the Underwriting Department of the Merchant Account provider to obtain the information needed to allow your Authorize.Net account to process Live transactions. STEP 2: COMPANY OFFICER / OWNER / PRINCIPLE INFORMATION All fields required regardless of corporate structure of business. Company Officer / Owner / Principal Name: Title: Date of Birth: Residence Address: City: State: ZIP Code: Business Phone Number: Driver s License Number: Business Fax Number: Driver s License State: Social Security Number: Are there additional owners of the company? Yes No STEP 3: COMPANY INFORMATION Date Established: Number of Years in Current Location: Description of Products or Services Sold: URL (Web site address) or ebay Seller ID: Are your customers required to pay a deposit when ordering? Yes No Do you currently accept credit cards? Yes No If yes, Name of Processor: If you do not now, have you ever accepted credit cards? Yes No Reason for Cancellation: If yes, Name of Processor: Monthly Visa/MC sales (estimate): $ Average transaction amount: $ 1 Maximum per transaction amount: $ (required in order to underwrite your Merchant Account) Would you like to apply to accept American Express? Yes No Discover? Yes No Note: Discover charges a $25 setup fee If you currently accept American Express, what is your 10 digit account number? If you currently accept Discover, what is your 15 digit account number? What is your typical time frame until product/service is delivered? What is your refund/exchange/cancellation policy? (circle one): All Sales Final Exchange Only Other Number of days that you will issue a full refund? What is your warranty policy? (circle one): In-House Manufacturer Only Don t Have One Number of days that the product or service is under full warranty? Please include any additional comments you may have about your company, such as shipping, fulfillment, return or warranty policies that may help the bank underwrite your Merchant Account. If your Web site is not complete, please provide a completion time estimate. 2
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