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

$ 25.0000

Discount Type

Daily

Early Termination Fee

ETF Fee

$ 750.0000

ETF Fee Contract Months

Pricing Type

	Per Item	Percent
Interchange	Pass Through Interchange
Credit Card	$ 0.00	0.30 %
Debit Card	$ 0.00	0.30 %

	Per Item	Percent
Interchange	Pass Through Interchange
Credit Card	$ 0.00	0.30 %
Debit Card	$ 0.00	0.30 %

	Per Item	Percent
Interchange	Pass Through Interchange
Credit Card	$ 0.00	0.30 %
Debit Card	$ 0.00	0.30 %

	Per Item	Percent
Qualified Discount	$ 0.10	0.50 %
Pass Thru IC Daily	Pass Through Interchange

AUTHORIZATION, MONTHLY & SPECIAL PROGRAM FEES

Name	Per Item
VS/MC/DISC Auth Fee	$ 0.15
Amex Auth Fee	$ 0.15
Pin Debit (Auth Per Item)	$ 0.25
Statement Fee	$ 0.00
Pin Debit Access (Monthly)	$ 0.00
Chargeback Fee	$ 25.00
Retrieval Fee	$ 5.00
ACH Reject Fee	$ 25.00

Name	Per Item
EBT Trans fee	$ 0.25
Voice Authorization	$ 0.95
AVS	$ 0.02
PCI Non-compliance Fee	$ 21.95
1099K Reporting Fee	$ 0.00
TIN Mismatch	$ 9.95
Merch Annual Fee	$ 0.00
PCI Annual Fee	$ 0.00
Batch Fee	$ 0.15

Standard Fees

Name	Per Item
Dial Pay	$ 0.95
Online Portal Fee	$ 0.00

Name	Per Item	Percent
MOTO/Ecomm Surcharge PI	$ 0.00	100.00 %
Next Day Funding	$ 0.00

Card Brand Fees

Name	Per Item
Card Brand Fees	Pass Through Card Brand Fee

Name	Per Item
Mastercard License Fee	Pass Through Expense

Debit Pin And EBT

Name	Per Item
Pin Debit Pass thru IC	Pass Through Interchange

Name	Per Item	Percent
Pin Debit Qualified Discount	$ 0.00	0.30 %
Pin Debit Annual Fee	$ 0.00

Gateway and Wireless Products Fees

Name	Per Item
Micros Fee	$ 0.059
Gateway Access Fee	$ 0.00
Gateway Per Item	$ 0.00

Name	Per Item
Wireless Activation	$ 0.00
Wireless & Mobile POS P/I	$ 0.00
Wireless Access Fee	$ 0.00

Equipment

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

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