Online Merchant Application

Legal Entity Address

Name*

Address Search

Address*

City*

State*

Postal Code*

Contact Phone*

Fax*

DBA Address

Name*

Address Search

Address*

City*

State*

Postal Code*

Contact Phone*

Fax*

Business Information

Date of Start Business*

# of locations*

Federal Tax Id#*

Mailing Address*

Email*

Website*

Select type of business*

Are you selling CBD/Delta 8/10/HHC etc, Nutraceuticals or Kratom?*

Do you provide massage services?*

Are you selling Gas or Fuel?*

Additional Information for Ownership*

Bankruptcy*

Business*

Personal*

Bankruptcy Date*

Fees Program

Each individual who owns, directly or indirectly through any contract, arrangement, understanding relationship or otherwise, 25% or more of the equity interests of the Client, or who is the Client‘s sole proprietor, must be added.

Primary Owner

Title*

First Name*

Middle Name*

Last Name*

Address Search

Home Address*

City*

State*

Zip Code*

Home Phone*

Date Of Birth*

SSN*

Type of Document ID*

Driver License / Document ID #*

% Of Ownership*

Email*

Guarantor*

Secondary Owner

Title*

First Name*

Middle Name*

Last Name*

Address Search

Home Address*

City*

State*

Zip Code*

Home Phone*

Date Of Birth*

SSN*

Type of Document ID*

Driver License / Document ID #*

% Of Ownership*

Email*

Guarantor*

Third Owner

Title*

First Name*

Middle Name*

Last Name*

Address Search

Home Address*

City*

State*

Zip Code*

Home Phone*

Date Of Birth*

SSN*

Type of Document ID*

Driver License / Document ID #*

% Of Ownership*

Email*

Guarantor*

Fourth Owner

Title*

First Name*

Middle Name*

Last Name*

Address Search

Home Address*

City*

State*

Zip Code*

Home Phone*

Date Of Birth*

SSN*

Type of Document ID*

Driver License / Document ID #*

% Of Ownership*

Email*

Guarantor*

Business Profile

Type of Ownership

Business Type*

Description of Products or Services Sold*

Description Refund / Return Policy*

Do you want to open Netevia Banking account?

Or enter manually

Select Checking Account*

Primary Bank Name*

Transit Routing No.*

Account Number*

Sales Profile

Are you currently accepting VISA/MASTERCARD/DISCOVER® NETWORK?*

Avg. Sale*

Max. Sale*

Monthly Sales Volume*

Estimate your sales percentage by category. Total must be 100%.

Retail Chip/Swipe*

Imprint (Card Present)*

Mail/Phone*

Internet*

Estimate your sales percentage by category. Total must be 100%.

Sales to businesses*

Sales to consumers*

Sales to goverment*

Authorized Person Title*

Percentage Ownership*

Employer Identification Number*

Minimum Discount Information

Minimum Amount

$ 0.0000

Discount Type

Daily

Early Termination Fee

ETF Fee

$ 0.0000

ETF Fee Contract Months

Pricing Type

	Per Item	Percent
Credit Card	$ 0.30	2.90 %
Debit Card	$ 0.30	2.90 %

	Per Item	Percent
Credit Card	$ 0.30	2.90 %
Debit Card	$ 0.30	2.90 %

	Per Item	Percent
Credit Card	$ 0.30	2.90 %
Debit Card	$ 0.30	2.90 %

	Per Item	Percent
Qual Discount	$ 0.30	2.90 %

AUTHORIZATION, MONTHLY & SPECIAL PROGRAM FEES

Name	Per Item
Chargeback Fee	$ 25.00

Name	Per Item
Retrieval Fee	$ 5.00
ACH Reject Fee	$ 25.00

Miscellaneous Fees (fixed)

Name	Frequency	Per Item
GATEWAY	Monthly	$ 10.00

Equipment

Title	Price	Monthly Payment	Deployment Status	Notes
open	$ 0.00	$ 0.00	NotSet

Copy of your business voided check, using your mobile phone camera or scanned copy in PDF, DOC, DOCX, JPG or PNG format

Add Voided Check

Merchant

Type Of Business*

Gift Loyalty

Time Zone*

Service Type*

Type of Program*

New Location* Gift*

Program Options And Card Designs

Pre Designed*

None*

PreDesigned 250*

PreDesigned 500*

Logo*

None*

Logo 100*

Logo 1000*

Proof - Waived before december 31st*

Optional additional lines of text: Phone#, address, etc.*

Card Type*

Design Card*

Text Color*

select type and design

Custom*

None*

Custom 250 (Custom Face Only)*

Custom 500 (Fully Custom)*

A-La-Carte*

Card Quantity (100 or more fully custom cards)

100-249 $0.95

250-499 $0.85

500-999 $0.50

1000-1,999 $0.33

2000-4,999 $0.30

5000-9,999 $0.29

10,000-24,999 $0.28

25,000-49,000 $0.20

50,000-99,999 $0.19

A-La-Carte Marketing Items	Quantity
Card Carriers - $0.20 ea.
4x6 Static Cling - $2.50 ea.
Round Sticker - $1.00 ea.
Table Tent - $2.50 ea.
Acrylic Display - $6.50 ea.
Metal Countertop Display - $14.95 ea.
Custom Card Carriers - request quote min. qty. 500

Custom Card Carriers QTY

500-999 $0.65

1000-2,999 $0.55

2,500-4,999 $0.45

Equipment

Terminal Type*

Number Of Terminals*

POS Software*

Version*

Number Of Workstations*

Shipping (billed to merchant)*

None*

Ground*

NextDay*

Program Options And Merchant Fees

Unlimited Program

Network Compliance Fee

Waived

Annual Subscription Fee

Waived

Location Service Fee

Waived

Transaction Fee Amount

Waived

Card Order

Reorder Cost Per Card*

$0.00

Package Cost*

$0.00

Loyalty Program Addendum

Loyalty Program Type*

None

Dollar Program

Frequency Program

Rewards are earned based on number of visits or number of items purchased
1 visit or purchase = 1 point or X # of dollars.
Points will continue to accumulate until the consumer chooses to redeem their reward.
Rewards can only be redeemed one at a time.
If the merchant chooses the reward to be a dollar amount, the value will be automatically placed on the gift/loyalty card.
Merchant determines what rewards to give for points accumulated
- Example 1: “Get 5 haircuts and 6th haircut is free” (not available on Nurit terminals)
- Example 2: “Buy 10 sandwiches and the 11th is free” (not available on Nurit terminals)
- Example 3: “Visit 10 times and earn XXX dollars on your loyalty/gift card”

Points Needed For Reward	Consumers’ Reward	Max Points Per Day That Can Be Added

NOTE: Rewards are available the following business day

Rewards are earned based on dollars spent
$1.00 spent = 1 Point
The dollar reward value will be automatically placed on the card once the consumer reaches the specified point level. Once a reward level is reached and the reward is added on the card, the dollar spending counter is reverted back to 0 and the consumer must spend the following amount to reach the next level.
Merchant determines what rewards to give for points accumulated
- Example 1: Single level of reward
  - Spend $100.................Receive a $10 reward on your card.
- Example 2: Multiple levels of rewards
  - Spend $100...........Receive a $15 reward on your card.
  - Spend $250...........Receive a $40 reward on your card.
  - Spend $500...........Receive a $70 reward on your card.

Award Level	Points Needed For Reward	Consumers’ Reward	Max Points Per Day That Can Be Added
1		$
2		$
3		$
4		$
5		$

NOTE: Rewards are available the following business day

Pricing Information