No preview available
HomeMy WebLinkAboutC20-003 Chase J.P. MorganAdditional Company Application Please print clearly. If you make any corrections to your information in the Application, you MUST initial each change. THIS SECTION IS FOR INTERNAL USE ONLY ECID: Application ID: Model from Merch #: Submitted by: Company #: What is this form?A Customer (you, your) can use this form to apply to add a location to receive services from Paymentech, LLC and JPMorgan Chase Bank, N.A. (“us”, “we”, or “our”). How do you complete the form? Complete all 3 parts, then print and sign the final version. Keep a copy for your records. The Customer section verifies your identity, which is necessary to comply with our policies designed to prevent money laundering and the funding of terrorism. Federal law requires us to obtain, verify and record certain information that identifies each person who opens an account with us. The Ownership section identifies the type of ownership for your business. The Certification section confirms that the Authorized Representative(s) has read and agreed to this document. DocuSign Envelope ID: CDF1B0BD-B1E0-4E0F-9A8A-D02B9F2288AA If you make any corrections to your information in the Application, you MUST initial each change. Application_GBL_US_CR418_Jan Rev. 2019-JAN Page 2 of 5 Part 1: Customer Complete all fields below 1.1 Company Information To help prevent the funding of terrorism and money laundering activities, Federal law and JPMC policies require us to obtain, verify, and record information that identifies each person who opens an account. In order to comply with these requirements, we will ask for your business name, physical address, and government identification number in order to verify your identity. Legal Name of Company to be Amended to the Agreement Business Start / Date of Incorporation (MM/DD/YYYY) Physical Address (No PO Box or Paid Mail Box) City State Zip Code Taxpayer ID / EIN Registered Trade Name (DBA Name) Primary Contact Name Phone Bussiness Type Ownership Type Public Private Non-Profit Subsidiary of Public Company Ticker Symbol Stock Exchange Other : Entity Type:Individual / Sole Proprietor Corporation Partnership Government – Gov. Website URL LLC – If LLC, Taxed As: Business Description (Primary source of revenue for legal entity) State of Formation Date of Formation Trading Symbol Fiscal Year End (MM/DD/YYYY) Has Merchant Ever Filed For Bankruptcy? If, Yes, What Chapter? Filing Date Emergence Date Do the financials of The Additional Company Stand Alone or Consolidated? If, Consolidated, indicate name of the company the financials are included in What is the relationship between the additional company and the company which entered the agreement ? DocuSign Envelope ID: CDF1B0BD-B1E0-4E0F-9A8A-D02B9F2288AA If you make any corrections to your information in the Application, you MUST initial each change. Application_GBL_US_CR418_Jan Rev. 2019-JAN Page 3 of 5 Part 2: Ownership Each owner signing authorizes JPMorgan Chase Bank N.A. And Paymentech, LLC as part of this investigation, to obtain and review Third Party Credit Bureau Reports On Such Owner. Ownership details must be provided for each Individual or Legal Entity Owner with a 10% or greater ownership interest. 2.1 Owner # 1 Name (Individual/Sole Proprietor or Entity/Parent Company) SSN/EIN* or Non- US Person Corporate Title Percent of Ownership % Is the Owner listed above publicly traded? No Yes Stock Exchange Ticker Symbol Street Address (Individual/Sole Provider use home address) City State ZIP Code Country of Domicile Date of Birth Phone *For Non-US Persons: Social Security Number, Passport Number and Country of Issuance (or other similar identification number) may be substituted (For Canadian individuals, this field is optional) Government Issued ID # Type of ID (ex. Passport) Country of Issuance 2.2 Owner # 2 Name (Individual/Sole Proprietor or Entity/Parent Company) SSN/EIN* or Non- US Person Corporate Title Percent of Ownership % Is the Owner listed above publicly traded? Stock Exchange Ticker Symbol Street Address (Individual/Sole Provider use home address) (No PO Box or Paid Mail Box) City State ZIP Code Country of Date of Birth Phone *For Non-US Persons: Social Security Number, Passport Number and Country of Issuance (or other similar identification number) may be substituted (For Canadian individuals, this field is optional) Government Issued ID # Type of ID (ex. Passport) Country of Issuance No Yes Owner/Officer Addendum required (Sales Representative will provide) DocuSign Envelope ID: CDF1B0BD-B1E0-4E0F-9A8A-D02B9F2288AA If you make any corrections to your information in the Application, you MUST initial each change. Application_GBL_US_CR418_Jan Rev. 2019-JAN Page 4 of 5 2.3 Controlling Officer (an individual with significant responsibility for managing the legal entity) Name SSN/EIN* Date of Birth What is this officer’s role?Key Decision Maker (i.e. Senior Mgr.)Chief Executive Officer Chief Officer Chief Operations Officer Chairman President Other (specify): Sections above require a Date of Birth and SSN/EIN*(or if you selected “Non-Profit” in section 1.2) Board of Directors Select one: Voting Non-voting Street Address (Provide home address) (No PO Box or Paid City State Country ZIP Code *For Non-US Persons: Social Security Number, Passport Number and Country of Issuance (or other similar identification number) may be substituted (For Canadian individuals, this field is optional) Government Issued ID # Type of ID (ex. Passport) Country of Issuance 2.4 Authorized Representative Name Street Address (if individual use home address) (No PO Box or Paid Mail Box) City State Country ZIP Code DocuSign Envelope ID: CDF1B0BD-B1E0-4E0F-9A8A-D02B9F2288AA If you make any corrections to your information in the Application, you MUST initial each change. Application_GBL_US_CR418_Jan Rev. 2019-JAN Page 5 of 5 Part 3: Certification If the signer has not already provided it above, a residential address is preferred if available (No PO Box or Paid Mailbox). If not available, business address is acceptable. 3.1 Authorized Administrator for Account Boarding Authorized administrator for purposes ofaccount boarding and implementation means an owner, partner, officer, employee or other agent of the merchant that has been appointed by an excutive of merchant and who is duly authorized to provide information and execute documentation on behalf of and related to merchant in order to facilitate the initial set up of merchant’s account with Chase Paymentech. Per Chase Paymentech policy, authorized administrators are not permitted to modify the merchant’s account with Chase Paymentech after completion of the initial set up of merchant’s account. Such changes must be made, by an executive or financial contact, as applicable and as those roles are defined by merchant. (Photocopy of signature below is valid for the release of information requested and will remain valid until the termination or expiration of the Merchant Agreement) Merchant Name (Printed) Merchant Signature Merchant Title (Printed) Date Telephone Number Email Address 3.2 Certification I, the undersigned, being an officer/principal of ______________________________________________represent and warrant that the staements made on thisdocument are correct and factul. JPMorgan Chase Bank, N.A. (“Member”) and Paymentech, LLC (“Paymentech” or “Chase Paymentech”) are authorized to conduct any necessary investigation, including without limitation, authorization for bank to release standard banking information. (Photocopy of signature below is valid for the release of information requested and will remain valid until the termination or expiration of the Merchant Agreement) Merchant Name (Printed) Merchant Signature Merchant Title (Printed) Date Street Address City State Zip PAYMENTECH INTERNAL USE ONLY Submitter Name: DocuSign Envelope ID: CDF1B0BD-B1E0-4E0F-9A8A-D02B9F2288AA SUBMITTER MERCHANT PAYMENT PROCESSING INSTRUCTIONS AND GUIDELINES Paymentech Link2Gov, Corp 1. Your Acceptance of Cards all only only 2. Settlement DocuSign Envelope ID: CDF1B0BD-B1E0-4E0F-9A8A-D02B9F2288AA 3. Chargebacks 4. Data Security and Privacy do not 5. Funding Schedule DocuSign Envelope ID: CDF1B0BD-B1E0-4E0F-9A8A-D02B9F2288AA 6. Convenience Fee Transactions. 7. Definitions Application Card Chargeback Convenience Fee Transaction Customer Member Payment Brand Payment Brand Rules “Card Information” Paymentech we our us Security Standards Transaction [Signature page to follow] DocuSign Envelope ID: CDF1B0BD-B1E0-4E0F-9A8A-D02B9F2288AA 3DJHRI3D\PHQWHFK&RQWUDFW1RSGI 3OHDVHDFNQRZOHGJH\RXUUHFHLSWRIWKHVHLQVWUXFWLRQVDQGJXLGHOLQHVDQG\RXUDJUHHPHQWWRFRPSO\WKHUHZLWK 'DWH $JUHHGDQG$FFHSWHGE\ /LQN*RY&RUS 6HDERDUG/DQH6XLWH$)UDQNOLQ71 $GGUHVV 3ULQWRU7\SH  %\ DXWKRUL]HGVLJQDWXUH  %\1DPH7LWOH 3ULQWRU7\SH  'DWH $JUHHGDQG$FFHSWHGE\ +G/6RIWZDUH//& 66WDWH&ROOHJH%OYG6XLWH%UHD&$ $GGUHVV 3ULQWRU7\SH  %\ DXWKRUL]HGVLJQDWXUH  'DWH Agreed and Accepted by: 3$<0(17(&+//&IRULWVHOIDQGRQEHKDOIRI -3025*$1&+$6(%$1.1$ %\ 3ULQW1DPH 7LWOH 'DWH $GGUHVV1RUWKHDVWHUQ%RXOHYDUG6DOHP1+ Imran Zulfiquarwala - Office Assistant ,17(51$/3$<0(17(&+86( 0HUFKDQW1DPH EAGLE COUNTY, CO Agreed and Accepted by: EAGLE COUNTY, CO %\1DPH7LWOH 3ULQWRU7\SH 12/31/2019 %\1DPH7LWOH 3ULQWRU7\SH 12/31/2019 0(5&+$17/(*$/1$0( 3ULQWRU7\SH 500 BROADWAY, EAGLE, CO 81631 $GGUHVV 3ULQWRU7\SH  %\ DXWKRUL]HGVLJQDWXUH Jeff Shroll - County Manager DocuSign Envelope ID: CDF1B0BD-B1E0-4E0F-9A8A-D02B9F2288AA