<%@ Language=VBScript %> Electronic Check Recovery

CHEXpedite Electronic Check Recovery Merchant Application and Agreement
Merchant's Legal Business Name: DBA
Billing Address:
CityStateZip
Retail Location Address:
CityStateZip
Phone Number Fax Number E-Mail Address # of Locations
Contact Person Title
Website URL  
 
Ownership Year Acquired Federal Tax ID Social Security Number  
 
 

Banking Information

 
Name of Primary Bank Name on Account
Bank Representative Bank Phone Number
Bank Routing Number Account Number


The Undersigned certifies theaccuracy of all of the Merchant information provided herein and authorizes ECHO to investigate such information which may include personal credit reports on Merchant’s principals or information from other sources pertaining to the Merchant’s credit worthiness, financial responsibility or accuracy of any of the foregoing information. Merchant further agrees to notify ECHO of any and all changes, which may occur from time to time, relative to the information and statements contained herein.
 
Options
 
Reporting (choose one) Online     U.S. Mail Reports
Assignment to Secondary Collections 
Assignment of Checks not recovered electronically to Secondary Collections
 
Merchant hereby agrees to obtain a written authorization from each Check Writer for (a) the state allowed return check charge, and (b) the electronic re-presentment of the check, before submitting a returned check item to ECHO for Processing. Merchant will obtain suchcheck writer authorizations by the following method. Check below the method(s) to be used.

(Please choose one of the following authorization methods)
 
By stamping all checks with the stamp approved by CHEXpedite™ Electronic Check Recovery and having customer sign where indicated.  
 
By placing authorization language acceptable to ECHO on any invoice, remittance advice, check acceptance agreement, contract or similar document which has been signed by Customer.  
 
Signed authorization on receipt generated by point of sale device.  
 
This CHEXpedite™ Electronic Check Recovery Merchant Agreement (Agreement) is between the above named merchant (Merchant0, Electronic Clearing House Inc. (ECHO), 28001 Dorothy Drive, Agoura Hills, CA 91301, and First Regional Bank (ODFI), 28310 Roadside Drive, Suite 152, Agoura Hills, CA 91310. This Agreement is an integrated agreement, and all prior negotiations, agreements and understandings, whether oral or written are therefore integrated herein. No modification or amendment of this Agreement shall be effective unless it is in writing and signed by all parties. The Officer signing below certifies that he/she is authorized and empowered to execute this Agreement on behalf of Merchant and to bind Merchant to the terms and conditions stated herein.
 
Agreed and Accepted <%= formatdatetime(now(), vbshortdate) %> Agreed and Accepted <%= formatdatetime(now(), vbshortdate) %>
 
Name of Authorized Signer
Licensee Name Licensee Number  
_______________________ _______________________  
 
Sales Rep Name Sales Rep Number  
 
 
_______________________ _______________________  
 
Please review information before clicking 'Print Form'