Merchant Application Fax completed applications to 1-215-494-0099

SALES OFFICE NAME

NEW APPLICATION

OFFICE PHONE NUMBER OFFICE CODE

MERCHANT ID# UNDERWRITER SCORE

D/B/A NAME - OUTLET NAME MERCHANT’S LEGAL NAME

LEGAL ADDRESS

CITY, STATE, ZIP

PHYSICAL STREET ADDRESS (NO P.O. BOX)

CITY, STATE, ZIP

DBA PHONE NUMBER DBA FAX NUMBER DBA PHONE NUMBER

EMAIL

WEBSITE ADDRESS (Required for any merchant with a website)

DBA FAX NUMBER

CONTACT

CUSTOMER SERVICE PHONE # (Required for MOTO and Internet merchants)

ADDITIONAL LOCATION OWNERSHIP CHANGE

Merchant Information Failure to provide accurate name and Tax ID number as reported to the IRS may result in withholdings of merchant funds per IRS regulations enacted January 2013

TYPE OF OWNERSHIP

MARKET TYPERETAIL

PREPAYMENT FOR FUTURE DELIVERY OF PRODUCTS/SERVICES(To be completed by Merchant)

CARD SWIPED %

%

%

%%

KEYED WITH IMPRINT MO/TO & INTERNET

TYPE OF GOODS OR SERVICES SOLD

YEAR BUSINESS STARTED YEARS OWNED

HAS MERCHANT EVER FILED FOR BANKRUPTCY?

DO YOU CURRENTLY ACCEPT VISA/MASTERCARD/DISCOVER?

1-7 DAYS 8-30 DAYS 30-60 DAYS

MONTH-MONTH QUARTERLY ANNUALLY OTHER:

SOLE PROPRIETOR PARTNERSHIPOTHERCORPORATION TAX EXEMPT ORG. (501C)

LLC

YES NO

YES NO

IF YES, HAVE BANKRUPTCIES BEEN DISCHARGED OR DISMISSED?

YES NO

YES NO

NO YES

MONTHLY VOLUME

ACCOUNT 1

MERCHANT’S SIGNATURE DATE

REV. 03/14-ACS-WF Pg.1 ALPHA CARD SERVICES, LLC IS A REGISTERED ISO/MSP OF WELLS FARGO BANK

MERCHANT’S PRINTED NAME & TITLE

ROUTING NUMBER DDA/CHECKING ACCOUNT #

$ $ $AVERAGE TICKET AMOUNT HIGHEST TICKET AMOUNT

SUPERMARKETRESTAURANT MO/TOLODGING E-COMMERCE

DEPOSIT DISCOUNT CHARGEBACK EQUIPMENT SUPPLIES MISC

TOTAL: 100%

Merchant Profile

Account Profile

Future Service/Delivery Information

YES NO If “yes”, please attach details.

Bank Information (attach pre-printed voided check or bank letter)

Is any owner, officer, director, employee, or agent a current or former official in the executive, legislative, administrative, military, or judicial branch of any government (elected or not); an official of a political party; an executive of a government-owned commercial enterprise; a family member of any of the foregoing officials; or a close personal or professional associate of any of the foregoing officials?

FEDERAL TAX ID#

Member Bank (Acquirer)WELLS FARGO BANK1200 MONTEGOWALNUT CREEK, CALIFORNIA 94598(925) 746-4167IMPORTANT MEMBER BANK (ACQUIRER) RESPONSIBILITIES1. The Bank is the only entity approved to extend acceptance of Card Organization products directly to a merchant.2. The Bank must be a principal (signer) to the Merchant Agreement.3. The Bank is responsible for and must provide settlement funds to the merchant.4. The Bank is responsible for all funds held in reserve.5. The Bank is responsible for educating merchants on pertinent Card Organization Rules with which merchants must comply; but this information may be provided to you by Processor.

For questions regarding Card Services, Contact:ALPHA CARD SERVICES, LLC.ATTN: CUSTOMER SERVICE1210 NORTHBROOK, STE 475TREVOSE, PA 19053

*NOTE: BILLING DISPUTES MUST BE FORWARDED, IN WRITING, TO CUSTOMER SERVICE WITHIN 60 DAYS OF THE DATE OF THE STATEMENT AND/OR NOTICE

IMPORTANT MERCHANT RESPONSIBILITIES1. Ensure compliance with cardholder data security and storage requirements.2. Maintain fraud and chargebacks below Card Organization thresholds.3. Review and understand the terms of the Merchant Agreement.4. Comply with Card Organization rules.

The responsibilities above do not replace terms of the Merchant Agreement and are provided to ensure the Merchant understands some important obligations of each party and that the Bank is the ultimate authority should the Merchant experience any problems.

CELL PHONE NUMBER

A) DOES THE MERCHANT TAKE ANY MONEY IN ADVANCE (deposits, down payments, etc.) BEFORE THE FINAL PRODUCT OR SERVICE IS RECEIVED BYCUSTOMER?If “Yes,” please complete Questions b-e; please use Comments section on Page 4elaborate if needed)

B) WHAT PERCENT OF WORK/GOODS IS TYPICALLY TAKEN AS A DOWN

C) WHAT PERCENT OF TOTAL CREDIT CARD TRANSACTIONS ARE FROM BUSINESS INVOLVES PAYMENT?

D) AFTER TAKING PAYMENT, WHEN IS PRODUCT OR SERVICE DELIVERED?

E) DOES MERCHANT BILL ON A RECURRING BASIS?(On what basis?)

APPROVAL REQUIREDDAILY DISCOUNT MONTHLY DISCOUNT SEASONAL BUSINESS (Open only part of the year):

(Check the months you are open)J F M A M J J A S O N D

MERCHANT INITIALS

30 + DAYS

VISA, MASTERCARD & DISCOVER PLAN TYPE:

TIER 1 + 1.69% + 10 CENTS

Credit/Debit Card Services and Fee Schedule*

REV. 03/14-ACS-WF Pg.2 ALPHA CARD SERVICES, LLC IS A REGISTERED ISO/MSP OF WELLS FARGO BANK

INTERCHANGE, DUES & ASSESSMENTS +

CHECK CARD TRANSACTION FEE TRANSACTION FEES MONTHLY FEES ANNUAL FEES

CREDIT CARD TRANSACTION FEE

NETWORK ACCESS FEE

WIRELESS SERVICE FEEWIRELESS FEEWIRELESS ACTIVATION FEE

INTERNET GATEWAYINTERNET FEE

$0.00 SETUP FEE ALPHA CARD GATEWAY$99.00 SETUP FEE AUTHORIZE.NET

2-TIER (MOTO/E-COMMERCE ONLY)TIER 1TIER 2

%

%

$

TIER 1 + 1.59% + 10 CENTS

3-TIER TIER 1TIER 2TIER 3

%4-TIER TIER 1TIER 2TIER 3TIER 4

%

¢

¢

¢0.05¢ 23.99

$50.00

$

$

$99.00

0.05¢

%

TIER 1 + 2.15% + 10 CENTSTIER 2 + 1.59% + 10 CENTSTIER 2 + 2.15% + 10 CENTS

SMARTPHONE PROCESSING

*ADD’L $10.00 PER MONTH & .05¢ PER TRANSACTION *ADD’L $10.00 PER MONTH & .05¢ PER TRANSACTION

PIN BASED DEBIT

INCLUDE NETWORK PASS-THROUGHALPHA CARD GIFT CARD

ONLINE STATEMENT

POS SYSTEMS PAYROLL SERVICES MERCHANT CASH ADVANCE GIFT & REWARD CARDS ATM SERVICES

PAPER STATEMENT

AVS TRANSACTION FEE +

SUPPLY AND WARRANTY$19.95 PER MONTH FOR WIRELESS TERMINALS

¢

$29.95/MO.

0.05¢

$79.00

$139.00

ANNUAL FEETO BE BILLED WITHIN 30 TO 60 DAYS AFTER THE APPROVAL OF MERCHANT ACCOUNT AND EACH AND EVERY FEBRUARY THEREAFTER.

QUICKBOOKS ACCTG PROCESSING

IMIS ONLINE ACCOUNT REPORTING

TO LEARN MORE ABOUT OTHER RELATED ALPHA CARD PRODUCTS, PLEASE CHECK THE APPROPRIATE BOX(ES) BELOW AND AN ALPHA CARD SALES REPRESENTATIVE WILL CONTACT YOU WITH MORE INFORMATION:

EBT

FCS#

DATA BREACH SERVICE PLUS$89.99 ANNUAL DBSP FEE

$795 MONTHLY DBSP FEE

MANUAL IMPRINTER $18.95

FREE

¢

***Transactions that do not qualify for the most favorable interchange rates will be subject to increased interchange rates. See the card services terms and conditions for more information regarding the circumstances in which increased interchange rates may apply. In addition to the per item fee, all debit transactions may include fees assessed by the applicable organization including a $5.00 per month for access to those networks. There are also fees for services of the following: Pass through of any and all Visa, Mastercard, Discover Access fees as covered by section 31, 0.35¢ Batch Settlement Fee, $35.0$ monthly minimum, $10.00 per reprinted monthly statement, $3.00 EBT Network Access Fee, 0.99¢ Monthly Regulatory Compliance Fee, $19.95 monthly non-receipt of PCI/DSS compliance fee, $5.00 per print screen of detailed batch report, $5.00 per print screen of batch totals, $5.00 per print screen of funds transfer, $35.00 per chargeback, $25.00 per retrieval request, $10.00 per Designated Account Change, $1.75 per voice authorization, $85.00 Site Inspection Fee, $25.00 per ACH reject, $.20 per declined or non captured card. By signing below merchant acknowledges that they have read and agree to section 13 regarding the term and termination procedures of this contract and any possible early termination fees that may be applicable.

MERCHANT INITIALS

(AFTER 60 DAY FREE TRIAL)

PRIMARY EMAIL ADDRESSFOR ADDITIONAL USERS PLEASE INCLUDE USER NAME AND EMAIL ON A SEPARATE FORM

DECLINE IMPRINTER: BY CHECKING HERE AND SIGNING THE AGREEMENT, MERCHANT ACKNOWLEDGES TO PROCESSOR THAT A MANUAL IMPRINT IS REQUIRED FOR ALL NON-SWIPED TRANSACTIONS.

MID #

$5.00

DAILY TRANSACTION INFORMATION $9.95

Owner/Officer Information (Please complete for every person who ultimately owns or controls the operation or on whose behalf the transactions authorized under this agreement will be conducted)

OWNSRENTS

NAMEAPPLICANT #1:

APPLICANT #2: (REQUIRED IF APPLICANT 1 HAS LESS THAN 50% OF OWNERSHIP)

TITLE % OWNERSHIP DATE OF BIRTH SOCIAL SECURITY# HOME PHONE#

HOME ADDRESS CITY STATE ZIPCODE YEARS THERE

OWNSRENTS

FORMER ADDRESS (IF LESS THAN 1 YR AT CURRENT ADDRESS) CITY STATE ZIPCODE YEARS THERE

OWNSRENTS

NAME TITLE % OWNERSHIP DATE OF BIRTH SOCIAL SECURITY# HOME PHONE#

HOME ADDRESS CITY STATE ZIPCODE YEARS THERE

QWICKPAY PROCESSING(FREE CARDREADER AND SOFTWARE FOR IPHONE,IPAD, ITOUCH & ANDROID PHONE)

(SOFTWARE SETUP FOR WINDOWS MOBILE & BLACKBERRY DEVICES)

AMEX TRANSACTION FEE

PER TERMINAL

POS SYSTEMS PAYROLL SERVICES MERCHANT CASH ADVANCE GIFT & REWARD CARDS ATM SERVICES

PAYPAL CREDIT (card present) ¢

¢

¢

REV. 03/14-ACS-WF Pg.3 ALPHA CARD SERVICES, LLC IS A REGISTERED ISO/MSP OF WELLS FARGO BANK

***** PCI DSS and card association rules prohibit storage of track data under any circumstances. If you or your POS system pass, transmit, store or receive full cardholder's data, then the POS software must be PA DSS (Payment Application Data Security Standard) compliant or you (merchant) must validate PCI DSS compliance (see 1(b) below and questions 3 and 4 must be completed). If you use a payment gateway, they must be PCI DSS compliant.*****

1. Have you ever experienced an Account Data Compromise "ADC"? If yes, provide date of compromise: a) Have you validated PCI DSS (Payment Card Industry Data Security Standard) compliance? If yes, go to 1(b); If no, go to #2 b) Date of compliance, Report on Compliance "ROC" or Self Assessment Questionnaire "SAQ"? c) What is the name of your Qualified Security Assessor "QSA" or Self Assessment Questionnaire (check one "SAQ") d) Date of last scan Approved Scanning Vendor's name:2. Are you using a "dial-up" terminal or “TTC” Touch Tone Capture? 3. Do you or your Service Provider(s) receive, pass, transmit or store the Full Cardholder Number "FCN", electronically? a) If yes, where is card data stored? Merchant’s location only Merchant’s Headquarters/Corp office only Primary Service Provider Both Merchant & Service Provider(s) Other Service Provider All Apply4. What Primary Service Provider/Software Developer did you purchase your point of sale “POS” application from (ie software, gateway)? a) What is the name of the Service Provider/Software Developer’s software application? Software Version #? b) Do your transactions process through any other Service Provider (ie web hosting companies, gateways, corporate office)? c) If yes, name the other Service Provider?

As required under the Payment Card Industry Data Security Standard (PCI DSS), Merchant declares and confirms the following:-Merchant is in compliance with all PCI DSS requirements.-Merchant’s point of sale software, system or application does not store sensitive authentication data after authorization.-Merchant will maintain full PCI DSS compliance at all times and will notify Global Payments when it changes its point of sale software, system or application.-None of Merchant’s systems store any evidence of magnetic stripe data, or PIN data after transaction authorization is completed.

Cardholder Data Storage Compliance & Service Provider

Yes No

Yes No

Yes NoYes No

Yes No

Yes NoYes NoYes NoYes No

A B DC

Acceptance of Merchant Application and Terms & Conditions/Merchant AuthorizationYour Card Services Agreement is between Global Payments Direct, Inc. ("Global Direct"), the Merchant named above, 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").A copy of the Card Services Terms and Conditions,revision number 10/13-ACS-WF, has been provided to you.Please sign below to signify that you have received a copy of the Card Services Terms & Conditions and that you agree to all terms & conditions contained therein. If this Merchant Application is accepted for card services, Merchant agrees to comply with the Merchant Application and the Card Services Terms & Conditions as may be modified or amended in the future. If you disagree with any Card Services Terms & Conditions, do not accept service. IF MERCHANT SUBMITS A TRANSACTION TO GLOBAL DIRECT HEREUNDER, MERCHANT WILL BE DEEMED TO HAVE ACCEPTED THE CARD SERVICES TERMS & CONDITIONS.

By your signature below on behalf of Merchant, you certify that all information provided in this Merchant Application 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 Terms and Conditions. In addition by your signature below on behalf of Merchant you authorize Global Direct and/or Alpha Card Services, Inc. to order a consumer credit report on you, Merchant and each of Merchant’s officers, partners, and/or owners, as well as subsequent consumer credit reports, which may be required or used in conjunction with the maintenance, updating, renewal or extension of the services provided hereunder, or in conjunction with reviewing, taking collection action on, or other legitimate purposes associated with the Merchant account.

MERCHANT’S SIGNATURE NAME (PRINTED) TITLEX

DATE

MERCHANT’S SIGNATURE NAME (PRINTED) TITLEX

DATE

SIGNING FOR GLOBAL PAYMENTS DIRECT, INC. NAME (PRINTED) TITLEX

DATE

SIGNING FOR MEMBER NAME (PRINTED) NAME OF MEMBER (PRINTED)HSBC BANK USA, NAX

DATE

Personal GuarantyI/We hereby irrevocably guarantee to Global Direct & Member, their successors & assigns, the full, prompt, & complete performance of Merchant & all of Merchant's obligations under the Card Services Agreement, including but not limited to all monetary obligations arising out of Merchant's performance or non-performance under the Card Services Agreement, whether arising before or after termination of the Card Services Agreement. This guaranty shall not be discharged or otherwise affected by any waiver, indulgence, compromise, settlement, extension of credit, or variation of terms of the Card Services Agreement made by or agreed to by Global Direct, Member, and/or Merchant. I/We hereby waive any notice of acceptance of this guaranty, notice of nonpayment or nonperformance of any provision of the Card Services Agreement by Merchant, and all other notices or demands regarding the Card Services Agreement. I/We agree to promptly provide to Global Direct and Member any information requested by any of them from time to time concerning my/our financial condition(s), business history, business relationships, and employment information. I/We agree that Global Direct and Global Direct (on behalf of Member) may order a consumer credit report on me, Merchant and each of Merchant’s officers, partners, and/or owners, as well as subsequent consumer credit reports, which may be required or used in conjunction with the maintenance, updating, renewal or extension of the services provided hereunder, or in conjunction with reviewing, taking collection action on, or other legitimate purposes associated with the Merchant account. I/We have read, understand, and agree to be bound by the Card Services Terms & Conditions provided to Merchant and those terms and conditions contained in this Merchant Application.

SIGNATURE OF GUARANTOR (PLEASE SIGN BELOW) NAME (PRINTED)X , an individualSIGNATURE OF GUARANTOR (PLEASE SIGN BELOW) NAME (PRINTED)

X , an individual

MERCHANT INITIALS

REV. 03/14-ACS-WF Pg.4 ALPHA CARD SERVICES, LLC IS A REGISTERED ISO/MSP OF WELLS FARGO BANK

TERMINAL TYPE

TERMINAL SOFTWARE

PIN PAD TYPEQUANTITY SUPPLIER

Terminal Setup Instructions

OTHER

RETAIL RESTAURANT MO/TO LODGING QSR SUPERMARKET E-COMMERCE*

TERMINAL FEATURES (CHECK ALL THAT APPLY)

INITIAL SETUP FEES

SPECIAL INSTRUCTIONS/COMMENTS

EQUIPMENT PAYMENT

SHIP TO:

TYPE:(ALL PACKAGES ARE SHIPPED UPS SIGNATURE REQUIRED & MUST GO TO A PHYSICAL ADDRESS)

GIFT CARD CHECK SERVICESDEBIT

CASHBACK MAXEBT FOOD STAMPSEBT CASH BENEFITSTIP LINE

NON-ACS GIFT CARD SERVICE

CREDIT CARD COD/CHECKACH REP RESIDUALS

LEASE SPLIT-FUND ACH MERCHANT

NEXT DAY AM 3 DAY SELECT GROUNDNEXT DAY STAND. 2 DAY

DBA LEGAL HOME SALES REP

DOWNLOADING INFORMATONTECH PLEASE CONTACT MERCHANT TO REPROGRAM TERMINALFAX DOWNLOADING INSTRUCTIONS TO:EMAIL DOWNLOADING INSTRUCTIONS TO:

ACS GIFT CARD PROGRAM

READER/IMAGER TYPE

NON-ACS CHECK SERVICESACS IMAGING CONVERSIONACS NON-IMAGING CONVERSION

SERVER #’S

AUTO BATCH TIME

INVOICE #’SLEVEL 2 PROMPTSIP PROCESSINGWIRELESS PROCESSING

NON-REFUNDABLE APP. FEE

REPROGRAMMING FEE SUBTOTALTAXTOTAL

FIRST & LAST PAYMENTEQUIPMENT PURCHASEOTHER SETUP FEE

PBX #

ACS

( %)

American ExpressEXISTING AMERICAN EXPRESS MID

By signing below, I represent that I have read and am authorized to sign and submit this application on behalf of the entity above and all information I have provided herein is true, complete, and accurate. I authorize American Express Travel Related Services Company, Inc. (“American Express”) to verify the information in this application and receive and exchange information about me personally, including by requesting reports from consumer reporting agencies. I authorize and direct American Express to inform me directly, or through the entity above, of reports about me that American Express has requested from consumer reporting agencies. Such information will include the name and address of the agency furnishing the report. I understand that upon American Express’ approval of the entity indicated above to accept the American Express Card, the terms and conditions for American Express® Card Acceptance (“Terms and Conditions”) will be sent to such entity along with a Welcome Letter. By accepting the American Express Card for the purchase of goods and/or services, or otherwise indicating its intention to be bound, the entity agrees to be bound by the Terms and Conditions.

APPLY FOR AMERICAN EXPRESS ACCEPTANCE

MERCHANT’S SIGNATURE NAME (PRINTED) TITLE

X

DATE

MERCHANT LOCATION:

DOES THE AMOUNT OF INVENTORY AND MERCHANDISE ON SHELVES APPEAR TO BE CONSISTENT WITH THE TYPE OF BUSINESS?

DOES THE MERCHANT USE A FULFILLMENT HOUSE?

THE MERCHANT:LANDLORD NAME LANDLORD PHONE NUMBER

FURTHER COMMENTS BY INSPECTOR:

Merchant Site Survey (to be completed by the sales representative)

YES NO

YES NOOWNSLEASES THE BUSINESS PREMISES

IF YES, WAS THE FULFILLMENT HOUSE INSPECTED?YES NO

RETAIL STORE FRONT OFFICE BUILDING INDUSTRIAL RESIDENCE OTHER

SQUARE FOOTAGE: 0-250 251-500 501-2000 2000+ SURROUNDING AREA: COMMERCIAL INDUSTRIAL RESIDENTIAL

I HEREBY VERIFY THAT THIS APPLICATION HAS BEEN FULLY COMPLETED BY MERCHANT APPLICANT AND THAT I HAVE PHYSICALLY INSPECTED THE BUSINESS PREMISES OF THE MERCHANT AT THIS ADDRESS AND THE INFORMATION STATED ABOVE IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.

AGENT SIGNATURE AGENT NAME (PLEASE PRINT) SALES REP ID DATE

OTHER ACS

OTHER ACS

MERCHANT INITIALS