MERCHANT

Synapse

EPI 1306

PAGE 2 OF 3

EPI 1306

5 | MERCHANT PROFILE AND PROCESSING SUMMARY
What is your annual gross business volume?
$
What is your annual credit card volume?
$
What is your average charge amount?
$
What is the highest charge you will need to process?
$
WHERE IS THE SALE TRANSACTED?
Merchant Location % Merchant Website % Mail/Telephone Order % Mobile Device %
HOW IS THE TRANSACTION COMPLETED?
Card/Chip Read % Manual Entry % Voice Authorization % Online Gateway %
When are your credit card sales deposited?
Date of Order Date of Delivery Other (please explain)
What is your refund policy? Explain if necessary:
No Refunds Exchange Only Full Refund Store Credit
What is the time frame for delivery of the product?
0-7 Days 8-15 Days 16-30 Days 30+ Days
Business Start Date

Are customers required to leave deposits?
Yes No If Yes, percentage required: %
Do you perform recurring transactions or auto-renewals? (Please explain)
Yes No
6 | MERCHANT SITE SURVEY AND SUMMARY
Merchant location has been physically inspected by agent
Yes No
Merchant lead was generated via the internet
Yes No
Give a detailed explanation of the merchandise and/or services sold/performed by the merchant:
Business Type
Retail Restaurant Lodging Petroleum
Tradeshow Car Rental Internet MO/TO
Business Location Type
0-7 Days Office Building Home - Based Restaurant Mixed Use Other class  
Does the merchant inventory and merchandise on shelves and floor appear consistent with the type of business specified above? (If no, please explain)
Yes No
Square footage
0-250 251-500 501-2,000 2,000+
I hereby verify that this application has been fully completed by the merchant and that 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. Any misrepresentation may result in losses and/or liabilities. EPI may contract with a third party to schedule an external site survey and I or the merchant will schedule an appointment immediately upon request.

James Ritter
PTS70
7 | EXISTING ENTITLEMENTS
Have you previous had an American Express SE #?
Yes No
8 |BANKING INFORMATION
Transit ABA Routing Number
DDA Account Number
9 | SERVICE FEE SCHEDULE
Visa Credit Visa Debit Discover® Network MasterCard Credit MasterCard Debit
American Express OptBlue® PIN Debit/ATM Electronic Benefits (EBT) Wright Express Voyager
SERVICE FEE SCHEDULE: American Express OptBlue®
OptBlue® Simplified Merchant Pricing
Simplified Merchant Pricing is based upon MCC code and varies between 2.65% to 3.6% for Qualified with additional surcharges and fees listed below, in the Program Guide and in your Welcome Kit.
OptBlue® Discount Rate plus Passthrough Interchange, Dues, Assessments, Fees and EPI Surcharges
American Express OptBlue® 2.89  0.10 
Prepaid Gift Card Charges and Fees: 2.89  0.10 
Select Grid: 7 - IC Plus* 22 - RCD 23 - Surcharge Other
Additional Fees Include:
An Inbound fee of 1% will be applied by American Express® to any Charge made by an American Express Cardmember using a Card issued by an American Express Issuer located outside of the United States.
0.30% downgrade will be charged by American Express® for transactions whenever a CNP or Card Not Present Charge occurs. CNP means a Charge for which the Card is not presented at the point of purchase (e.g., Charges by mail, telephone, fax or the Internet).
*0.30% to 1% processor settlement fee will be charged by Electronic Payments on any transactions processed and settled by Electronic Payments.
*0.165% Network Fee will be charged by American Express® on all sales.

Electronic Payments is a registered Independent Sales Organization of Wells Fargo Bank, N.A., Concord, CA