<%@ Language=VBScript %> Check Collect Merchant Application

CHEXpeditetm -Electronic Check Conversion
Merchant Application
 
Returned checks will be made payable to: 
Company Name(Corp. Office): 
Federal ID#:  State ID#:  Sales Tax#: 
HQ-Address:  Phone: 
    Fax:      
City: 
State:  Zip:   
Contact:  E-mail: 
Title:  Time-zone: 
Phone:  E-mail: 
Owner Name:  SSN: 
Home Address:   
City: 
State:  Zip:   
Business Type:
(check one)		 General Retail Home Center/Hardware Grocery Apparel/Shoes  
Auto Supply/Repair Gas/C-Store Liquor Drug Store  
Restaurant Video/Music/Books Recreational Motel/Hotel  
Health/Medical Insurance/Legal Mail Order Business/Service  
Personnel Service Other 
 
Legal Business Type:
(check one)		 S-Corporation C-Corporation Limited Liablility Partnership  
Proprietorship Non-Profit  
 
 

Banking Information: (This is the Bank to which company/merchant's funds will be electronically deposited, and electronically debited for the Setup Fee of $99.00 and the Terminal Programming Fee of $12.00 per terminal)
 
Name of Merchant Bank:  Phone: 
Name(s) on Account: 
Bank RTN:  Account Number: 
 
 

Action to be taken on an item after completion of Electronic Check Conversion process:
 
Return to Merchant: 
Peak Services: 
Send to other agency: 
 
Does the Company wish to impose limits on the individual amount, total amount or number of checks converted by the company? 

If yes, specify limits:
Number of checks per day  Dollar limit per check  Total dollar limit per day 
 
Does the Company wish to impose limits on the amount or number of checks from any one customer that can be converted? 

If yes, specify limits:
Number of checks per day Dollar limit per check  Total dollar limit per day 
Terminal Type/Model:  Check Reader Type/Model: 
Credit Card POS Terminal Type/Model:  Credit Card Program: 
Credit Card Merchant ID:  Credit Card Contact: 
Phone:   
 

The undersigned certifies the accuracy of all the foregoing information and authorizes the Bank or other investigative agency employed by Electronic Check Conversion™ to investigate the reference given to Electronic Check Conversion™ or statements or other data contained herein obtained from merchant or from other persons pertaining to merchant’s credit, financial responsibility or accuracy of any of the foregoing information.  I/We further agree to notify Electronic Check Conversion™ of any and all changes, which may occur from time to time in the information and statements contained herein.

 

Company agrees to obtain a written authorization for any truncated items submitted in accordance with the Electronic Check Conversion™ agreement.  Acceptable authorizations may be obtained as follows:  (INITIAL METHOD TO BE USED BELOW).

 

________  By having the (customer) sign the printed transaction receipt containing authorization language acceptable to and as approved by Electronic Check Conversion™.
 

ADDITIONAL TERMS AND CONDITIONS

This agreement is between the above named company/merchant and Electronic Check Conversion™, a division of National Bank Drafting Systems, Inc. , (NBDS, Inc.), a Texas Corporation, located at 6707 Brentwood Stair Rd., Suite 640, Fort Worth, Texas  76112.   This agreement constitutes the only agreement between the parties and all prior negotiations, agreements, and understandings, whether oral or written, are therefore superseded.  Any other processing agreements between NBDS, Inc. and the above named merchant shall not affect the terms of this agreement.  No modification or amendment of this agreement shall be effective unless in writing and signed by all parties.  The person signing this agreement certifies that he/she is authorized to enter into this agreement on behalf of the client.

 

Agreed to and accepted by
Company Representative

Electronic Check Conversion Representative
By:  By:Total Payment Solutions, Inc.
Date: <%= formatdatetime(now(), vbshortdate) %> Date: <%= formatdatetime(now(), vbshortdate) %>
 
Licensee Number: ______________________________ Rep Id#: ______________________________
Licensee Telephone: ______________________________ Rep. Name: ______________________________
 

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