Online Merchant Application

Legal Entity Address

Business Name*

Street Address*

Floor/Suite*

City*

State*

Zip Code*

Phone*

DBA Address

Business Name*

Street Address*

Floor/Suite*

City*

State*

Zip Code*

Phone*

Fax*

Prior Security Breach*

Number of Locations*

Date of Start Business *

Years Owned Business*

I certify that I am a foreign entity/nonresident alien. (If checked, please attach IRS Form W-8)*

Select type of business*

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.

Residence Street Address*

Country Of Citizenship*

Equity Ownership, %*

Residence Street Address*

Country Of Citizenship*

Equity Ownership, %*

Residence Street Address*

Country Of Citizenship*

Equity Ownership, %*

Residence Street Address*

Country Of Citizenship*

Equity Ownership, %*

Primary Operation Country*

Do you want to open Netevia Banking account?

Where should we deposit your processing funds?

Bank Name*

Name on Bank Account*

Routing/Transit Number*

Account Number*

Bank Phone*

Netevia Banking Account

First Name*

Middle Name*

Last Name*

Address Search

Street Address*

City*

State*

Zip*

Email*

Phone*

Date Of Birth*

SSN*

Authorized Person Title*

Percentage Ownership*

Employer Identification Number*

Transaction Profile

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

Card Swipe/Chip*

Manual Key Entry Or Imprint*

Mail/Phone Order*

Internet*

Transaction Volume

Monthly Sales Volume*

Avg. Sale*

Max. Sale*

Transaction Information

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

Sales to consumers*

Sales to businesses*

Sales to goverment*

Has Been Terminated*

Reason For Termination*

How will product be advertised or promoted?*

List name(s) and address (es) of vendor from which the product is purchased*

List name(s) and address (es) of third party or fulfillment organizations, or parties aside from your staff who will assist or participate with the sales, marketing, processing of orders or shipping of merchandise.*

List carrier service that will deliver product.*

What is your return or refund policy?*

When you receive an authorization, how long before merchandise is shipped or services are provided? (days)*

Do you perform recurring billing?*

What is the frequency?*

Is your database collecting entire credit card numbers?*

If so, are you PCI compliant?*

Internet Business Type

Web Hosting* Domain Registration*

Web Page Design* Internet Service Gateway*

Selling Digital Service* Auction*

Advertisement* Selling Hard Goods*

Other*

If using the Internet, list encryption method, vendor, and controls used to secure transaction information*

Monthly Card Volume*

Average Card Ticket*

Highest Card Ticket*

Accept Debit Transactions*

Accept EBT Transactions*

Is Inventory Consistent all year around?*

Please explain why your inventory is not consistent*

Pricing Type | By Card Brand

	Credit Card	Check Card
Rate	0.30%	0.30%
Per Item	$0.00	$0.00

	Credit Card	Check Card
Rate	0.30%	0.30%
Per Item	$0.00	$0.00

	Credit Card	Check Card
Rate	0.30%	0.30%
Per Item	$0.00	$0.00

	Credit Card
Rate	0.50%
Per Item	$0.10

	Credit Card	Check Card
Rate
Per Item	$0.00	$0.00

	Credit Card
Rate	0.50%
Per Item	$0.10

Interchange Fee | Pass Through Int

	MID-qualified	Non-qualified
Surcharge
Per Item	$0.00	$0.00

	MID-qualified	Non-qualified
Surcharge
Per Item	$0.00	$0.00

	MID-qualified	Non-qualified
Surcharge
Per Item	$0.00	$0.00

Other Fees

Name	Fee Amount
Micros Fee	$ 0.0595
ACH Reject Fee	$ 25.00
Retrieval Fee	$ 5.00
PCI Non-Complines Fee	$ 19.95
Monthly Minimum	$ 25.00
DISC/VS/MC Transaction Fee	$ 0.15
Non-Bankcard Transaction Fee	$ 0.15
Monthly Service	$ 2.00
Batch Fee	$ 0.15
Voice Authorization Fee	$ 0.95
Chargeback Fee	$ 25.00
AVS Surcharge Fee	$ 0.02
Government Compliance Fee	$ 3.95
TIN Mismatch Fee	$ 9.95

Name	Fee Amount
Early Termination Fee	$ 750.00
Touchtone IVR	$ 0.55
MasterCard MALF	0.012 %
Debit Transaction Fee	$ 0.25
EBT Statement Fee	$ 2.00
EBT Transaction Fee	$ 0.25

Copy of your state ID, drivers license and/or passport using your mobile phone camera or, scanned copy in PDF, JPG or PNG format

Add State ID

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