Extracted text (via pymupdf)
15112 characters
A Global Payments Company 1 | P a g e Revised: 01/25/23
ACTIVE Network Merchant Services Agreement
ACTIVE Network
Merchant Service Application
COMPANY INFORMATION
9TD-ANAN
181215
HSC
HSC
AFFILIATE NAME / NUMBER
PRICING CHAIN
ENTERPRISE RM NAME
ENTERPRISE RM PHONE
ACTIVE ACCOUNT
REPRESENTATIVE NAME
ACTIVE ACCOUNT
REPRESENTATIVE EMAIL
NUMBER OF LOCATIONS
STORE NUMBER
City of Chandler
merchant.services@activen
etwork.com
1800-663-4991
AUTHORIZED TO PURCHASE:
Yes
No
MERCHANT DBA NAME
PRIMARY CONTACT INTERNAL NAME
PRIMARY CONTACT PHONE
175 S. Arizona Ave.,
Chandler, AZ 85225
Kristi Smith
480-782-2332
DBA ADDRESS
DBA CITY / STATE / ZIP
DBA PHONE NUMBER
MERCHANT WEBSITE ADDRESS
City of Chandler
Tamara Sharp
N/A
AUTHORIZED TO PURCHASE:
Yes
No
LEGAL NAME
(MUST CORRESPOND WITH IRS FILING NAME)
SECONDARY CONTACT
INTERNAL NAME
SECONDARY CONTACT PHONE
175 S. Arizona Ave.
Chandler, AZ 85225
480-782-2332
86 600238
LEGAL ADDRESS
LEGAL CITY / STATE / ZIP
LEGAL PHONE NUMBER
MERCHANT FEDERAL TAX ID / EIN
ACTIVE Network, LLC
464960154
HEADQUARTERS / MANAGEMENT COMPANY NAME
(IF MANAGEMENT COMPANY, PROVIDE COPY OF MANAGEMENT AGREEMENT.)
ACTIVE FEDERAL TAX ID / EIN
10 Glenlake Pkwy NE, N Tower
Atlanta, GA. 30328
N/A
HEADQUARTERS ADDRESS
HEADQUARTERS CITY/STATE/ZIP
HEADQUARTERS PHONE
Tamara.Sharp@activenetwork.com
Tamara
Sharp
EMAIL ADDRESS (INFOCENTRAL ADMIN USER EMAIL ADDRESS)
EMAIL CONTACT FIRST NAME
EMAIL CONTACT LAST NAME
MEMBER SPONSOR BANK DISCLOSURE INFORMATION
Merchant Services Provider Contact Information: ACTIVE Network LLC (“ACTIVE”); 5850 Granite Parkway, Suite 1200 Plano, TX 75024;
(469) 291-0300 - Application Inquiries: Contact your Account Representative
MEMBER SPONSOR BANK (ACQUIRER) INFORMATION
Wells Fargo Bank, N.A. - P.O. Box 6079 - Concord, CA 94524
MERCHANT RESOURCES
1. You may download Visa Regulations from Visa’s website at: http://usa.visa.com
2. You may download Mastercard Rules from Mastercard’s website at: http://Mastercard.com
3. You may download additional merchant information from Discover at: http://www.discovernetwork.com/merchants/index.html
IMPORTANT MERCHANT RESPONSIBILITIES
IMPORTANT (ACQUIRER) RESPONSIBILITIES
1.
Merchant must ensure compliance with cardholder data security and storage requirements.
2.
Merchant must maintain fraud and chargeback below thresholds.
3.
Merchant must review and understand the terms of the Heartland Merchant Processing
Agreement.
4.
Merchant must comply with the Card Brands Operating Regulations.
5.
Merchant must retain a signed copy of this Disclosure Page.
Note: Merchant is responsible for providing accurate and up-to-date information. Merchant must
notify ACTIVE Network of any changes that occur to the information provided on this form, or any
changes in processing expectations (estimated volume, transaction price, future delivery,
chargeback rate, refund rate, refund policy, etc.); not doing so could put Merchant in Breach of
the Merchant Agreement.
Note: The responsibilities listed above do not supersede terms of the Merchant Processing
Agreement and are provided to ensure the merchant understands some important obligations of
each party and that the Member Sponsor Bank is the ultimate authority should the merchant have
any problems.
1.
The Member Sponsor Bank is the only entity
approved to extend acceptance of Card Brand
products directly to a Merchant.
2.
The Member Sponsor Bank must be a principal
(signer) to the Merchant Processing Agreement.
3.
The Member Sponsor Bank is responsible for
educating Merchants on pertinent Card Brand
Operating Regulations with which Merchants
must comply.
4.
The Member Sponsor Bank is responsible for
and must settle funds with the Merchant.
5.
The Member Sponsor Bank is responsible for
all funds held in reserve that are derived from
settlement.
ACKNOWLEDGEMENT
The responsibilities listed above do not supersede 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.
X
OWNER/OFFICER SIGNATURE
PRINT NAME & TITLE
EMAIL
DATE
DocuSign Envelope ID: F6F49E31-3081-470A-B88C-D6ED1DCAAD04
A Global Payments Company 2 | P a g e Revised: 01/25/23
ACTIVE Network Merchant Services Agreement
CARD FEE SCHEDULE
$
$
Cost Plus
See Pricing Schedule Attached
ANNUAL CARD VOLUME
AVERAGE TICKET
CARD PROCESSING
INTERCHANGE QUALIFICATION
DEPOSIT METHOD
CARD ACCEPTANCE
MOTO / INTERNET
Standard
All Cards Accepted
STATEMENT OPTIONS
DISPUTE LETTERS
STATEMENT TYPE
MAIL STATEMENTS TO
MAILING OPTIONS
ELECTRONIC OPTIONS*
Standard
Suppress Statements
Legal
Email
ALL ELECTRONIC COMMUNICATIONS: PREFERRED EMAIL ADDRESS: merchant.services@activenetwork.com
MERCHANT DETAIL
TYPE OF BUSINESS:
TYPE OF OWNERSHIP:
IRS REPORTING CLASSIFICATION FOR LLC:
BUSINESS IS CONDUCTED:
Private
Corporation
Corporation
CONSUMER:
100%
Public:
LLC
Partnership
BUSINESS TO BUSINESS:
0%
TICKER SYMBOL:
Government
Disregarded Entity
(Single Member LLC)
Non-Profit
DATE BUSINESS STARTED
DATE ACQUIRED BY
CURRENT OWNER
PRODUCT / SERVICES PROVIDED
HOW SOON IS THE CUSTOMER’S CARD
CHARGED
WHAT PERCENTAGE OF SALES
ARE CHARGEBACKS
WHAT PERCENTAGE OF
SALES ARE RETURNS
DEFINE CARD REFUND POLICY
(Refunds made via credit card must be applied to the card used at the time of sale.)
IS CREDIT CARD INFORMATION
PROCESSED VIA WEBSITE:
Yes
No
ARE WEB-BASED SALES
PROCESSED THROUGH ACTIVE:
Yes
No
N/A
IF NOT, PROVIDE NAME OF PAYMENT PROCESSOR UTILIZED FOR WEB-BASED TRANSACTIONS
SEASONAL MERCHANT:
Yes
No IF YES, SELECT MONTHS OPEN:
J
F
M
A
M
J
J
A
S
O
N
D
SALES METHOD
PROCESSING METHOD
FUTURE DELIVERY (FD)*
On Premise Face to Face Sales:
10%
Card Swiped:
10%
2 – 5 Days: %
* Includes advance
reservations, deposits
accepted for ordered
merchandise shipped after
payment, and services
provided after payment
including memberships and
subscriptions. If 100% of the
product and/or service are
NOT delivered (not including
mail time) within 24hrs of the
time of sale, indicate below:
Off Premise Face to Face Sales:
%
Keyed with Imprinted Receipt:
%
6 – 10 Day: %
Mail Order Sales:
%
Keyed without Imprinted Receipt:
90%
11 – 30 Days: %
Real-Time Internet Sales:
90%
TOTAL = 100%
31 – 60 Days: %
Inbound Telephone Order Sales: %
61 – 90 Days: %
Outbound Telephone Order Sales:
%
91 – 120 Days: %
Internet (keyed) : %
> 120Days: %
Recurring Billing:
%
IF APPLICABLE TOTAL = 100%
TOTAL = 100%
WHAT PERCENTAGE OF BANKCARD VOLUME IS “FD”: %
IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING A NEW ACCOUNT
To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record
information that identifies each person who opens an account. What this means for you: When you open an account, we will ask for your name, address, date
of birth, and other information that will allow us to identify you. We may also ask to see your driver’s license or other identifying documents.
AUTHORIZED SIGNER(S) INFORMATION
Note: Complete Owner / Officer Information must be present for all Equity Owners with 25% or greater equity in the business and for any person(s) with authority or control. Additional
owner/officer information may be provided on the Additional Owner/Officer Page as needed.
To the best of your knowledge indicate if any owner, officer, director, employee, or agent a current or former senior official in
the executive, legislative, administrative, military, or judicial branch of any government (elected or not); a senior official of a
Yes
No
If Yes, attach details.
DocuSign Envelope ID: F6F49E31-3081-470A-B88C-D6ED1DCAAD04
A Global Payments Company 3 | P a g e Revised: 01/25/23
ACTIVE Network Merchant Services Agreement
major 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:
(1)
Owner
Officer
Authorized Signer
Managing Agent (Please provide copy of Management Agreement)
NAME
TITLE
SOCIAL SECURITY NUMBER
DATE OF BIRTH (MM/DD/YYYY)
%
CITIZENSHIP:
U.S.
NON-U.S.
CELL PHONE NUMBER
DRIVER’S LICENSE NUMBER
BUSINESS EQUITY OWNERSHIP
HOME ADDRESS
HOME CITY
HOME STATE
HOME ZIP
(2)
Owner
Officer
Authorized Signer
Managing Agent (Please provide copy of Management Agreement)
NAME
TITLE
SOCIAL SECURITY NUMBER
DATE OF BIRTH (MM/DD/YYYY)
%
CITIZENSHIP:
U.S.
NON-U.S.
CELL PHONE NUMBER
DRIVER’S LICENSE NUMBER
BUSINESS EQUITY OWNERSHIP
HOME ADDRESS
HOME CITY
HOME STATE
HOME ZIP
PCI COMPLIANCE
IS YOUR BUSINESS PCI COMPLIANT:
Yes
No
DOES YOUR COMPANY UTILIZE A DATA STORAGE ENTITY OR MERCHANT SERVICER THAT HAS ACCESS TO CARD MEMBER DATA:
Yes
No (i.e., Payment gateway or data warehouse, etc.)
If yes, provide the name of the Data Storage Entity or Merchant Servicer being utilized:
N/A
PAYMENT CARD INDUSTRY DATA SECURITY STANDARDS ("PCI DSS") AND CARD NETWORK RULES PROHIBIT STORAGE OF SENSITIVE
AUTHENTICATION DATA AFTER THE TRANSACTION HAS BEEN AUTHORIZED (EVEN IF ENCRYPTED). IF YOU OR YOUR POS SYSTEM STORE,
PROCESS, OR TRANSMIT FULL CARDHOLDER’S DATA, THEN YOU (MERCHANT) MUST VALIDATE PCI DSS COMPLIANCE. IF YOU (MERCHANT)
UTILIZE A PAYMENT APPLICATION THE POS SOFTWARE MUST BE COMPLIANT WITH EITHER THE PCI SOFTWARE SECURITY FRAMEWORK
STANDARDS OR PA DSS (PAYMENT APPLICATION DATA SECURITY STANDARDS) UNTIL ITS EXPIRATION AT THE END OF OCTOBER 2022. IF
YOU USE A PAYMENT GATEWAY, THEY MUST ALSO BE PCI DSS COMPLIANT. AS REQUIRED UNDER PCI DSS, I DO HEREBY DECLARE AND
CONFIRM THE FOLLOWING:
MERCHANT WILL MAINTAIN FULL PCI DSS COMPLIANCE AT ALL TIMES AND WILL NOTIFY ACTIVE
WHEN IT CHANGES ITS POINT OF SALE SOFTWARE, SYSTEM, APPLICATION OR VENDOR:
Yes
No
N/A
DO YOUR TRANSACTIONS PROCESS THROUGH ANY OTHER THIRD PARTIES (I.E. WEB HOSTING
COMPANIES, GATEWAYS, CORPORATE OFFICE):
Yes
No
N/A
MERCHANT UTILIZES THE SERVICES OF A PCI SSC QUALIFIED INTEGRATOR RESELLER (QIR)
WHEN POS PAYMENT APPLICATIONS ARE UTILIZED:
Yes
No
N/A
THE SIGNING MERCHANT LISTED BELOW HAS EXPERIENCED AN ACCOUNT DATA
COMPROMISE.*:
Yes
No
N/A
I have never accepted payment cards.
If yes, what was the date of the compromise:
(Copy of the completed forensic investigation is required with the app.)
THE SIGNING MERCHANT LISTED BELOW IS STORING SENSITIVE AUTHENTICATION DATA**
(EVEN IF ENCRYPTED) AFTER THE TRANSACTION HAS BEEN AUTHORIZED:
Yes
No
N/A
I have never accepted payment cards.
MERCHANT UTILIZES AN EMV ENABLED TERMINAL:
Yes
No
N/A
DocuSign Envelope ID: F6F49E31-3081-470A-B88C-D6ED1DCAAD04
A Global Payments Company
4 | P a g e
Revised: 01/25/23
ACTIVE Network Merchant Services Agreement
*An Account Data Compromise is any incident that results in unauthorized access to payment card data and/or Sensitive Authentication Data.
**Sensitive Authentication Data is security related information (Card Verification Values, complete Magnetic Stripe Data, PINs, and PIN blocks) that is used
to authenticate cardholders.
Please note that if you have indicated that your organization has experienced an account data compromise in the past, a PCI DSS Level 1 Compliance
Assessment may be required upon ACTIVEs request. A compromise of cardholder data from your location(s) may result in the issuance of fines and/or
penalties by the card brand, for which you will be responsible under your Merchant Agreement, notwithstanding this Compliance Statement. It is imperative
that you notify ACTIVE immediately should the information on this Compliance Statement change.
AGREEMENT ACCEPTANCE, CERTIFICATION and CONSUMER REPORT AUTHORIZATION
I, the Merchant, authorizes ACTIVE, reporting agency employed by ACTIVE, or any agents thereof, to investigate the references, statements or data provided
by Merchant or the undersigned for purposes of all matters generally connected to this business relationship. I further certify that I have received, read,
understand and agree to the Heartland Merchant Processing Agreement Terms and Conditions, Policies, Procedures, Rules and Requirements for Card
which together with this application shall constitute the agreement(s) between the parties. In addition, Merchant can request another copy of the Terms and
Conditions at any time by sending a written request for a copy to ACTIVE at the following address: ACTIVE Network LLC (“ACTIVE”); 5850 Granite Parkway,
Suite 1200 Plano, TX 75024. I further certify that this business or any Owner/Officer/Authorized Signer has never been terminated as a Visa, Mastercard or
Discover Merchant. This document and all electronically executed documents related hereto are legally binding in the same manner as are hard copy
documents executed by hand signature.
X
OWNER/OFFICER SIGNATURE *
PRINT NAME & TITLE
EMAIL
DATE
X
OWNER/OFFICER SIGNATURE *
PRINT NAME & TITLE
EMAIL
DATE
PLEASE SEE AGREEMENT FOR THE TERM OF THIS APPLICATION
APPROVED AS TO FORM:
___________________________________________
City Attorney
ATTEST:
___________________________________________
City Clerk
DocuSign Envelope ID: F6F49E31-3081-470A-B88C-D6ED1DCAAD04