Instructions For Completing Merchant Processing Forms - PaymentBanc

MERCHANTP R O C E S S I N G A P P L I C AT I O N A N D A G R E E M E N T( 7 ) F L AT R AT E / I C P L U S / T I E R P R I C I N G S C H E D U L E (cont’d)STMS(TCK)1505PB003DBA Name:Pricing Type:(Page 3 of 6)OrthoPBCorpFee1511(ia)InterchangeSchedule Version:1 ofLoc.Discount Fees (Based On Gross Transaction Volume)Accept all MasterCard, Visa and Discover Network Transactions(presumed, unless any selections below are checked)MasterCard AcceptanceVisa AcceptanceDiscover Network Acceptance Accept MC Credit transactions only Accept Visa Credit transactions only Accept Discover Network Credit transactions only Accept MC Non-PIN Debit trans. only Accept Visa Non-PIN Debit trans. only Accept Discover Network Non-PIN Debit trans. onlySee Section 1.9 of the Program Guide for details regarding limited acceptance. You are responsible for distinguishing Credit from Non-PIN DebitCards. Even if you have agreed to limit your acceptance of certain cards as outlined above, you must continue to accept all foreign issuedcards, whether Credit or Non-PIN Debit. If you agree to limit your acceptance to a particular type of card and, whether intentionally or in error,accept another type of transaction, the resulting transaction will downgrade to the highest cost interchange plus the applicable Non-QualifiedSurcharge (See Section 18.1 of the Program erNetwork3-TierTransaction Fees(Applies to MC / Visa / Discover Network 2-TierandMC / Visa / Discover Network 3-Tier ONLY)%%MC / V/ Discover Network Qual CreditTrans Fee(001,002,005,006) (015,016) %MC / V/ Discover Network Qual Non-PIN DebitTrans Fee(130,131,134,135) (787,788) Pricing Method: (Select One)MC/Visa /DiscoverNetwork /American ExpressDiscount RateMC / Visa/ DiscoverNetwork IC Pass ThruYou will be charged theapplicable interchange ratefrom MC (564), Visa (549), orDiscover Network (527) plus aMC Assessment Fee (273) of0.11% [MC Assessment TranAmt 1K (237), an additional0.02% will be charged per MCsettled credit card sale whenthe transaction amount equals 1,000 or greater], a VisaAssessment Fee (274) of0.11%, or a Discover NetworkAssessment Fee (234) of0.105%, plus any other feesindicated on this Service FeeSchedule.QUALIFIED DISCOUNT RATESMC / Visa/ Discover NetworkCredit Discount Rate(800, 804, 170)American Express OnePoint**Credit Discount Rate*MC / Visa/ Discover NetworkNon-PIN Debit Discount Rate(Key 0-570)(850, 854, 964)%%%%%%MID-QUALIFIED DISCOUNT RATES (Does not apply to MC / Visa / Discover 2 Tier)*MC / Visa/ Discover NetworkCredit Discount Rate(810, 814, 990)%MC / Visa/ Discover NetworkNon-PIN Debit Discount Rate(870, 874, 968)%MC / V/ Discover Network Mid-Qual CreditTrans Fee(611,612,615,616) (717, 718) MC / V/ Discover Network Mid-Qual Non-PINDebit Trans Fee (140,141,144,145) (791,792) NON-QUALIFIED DISCOUNT RATES*MC / Visa/ Discover NetworkCredit Discount Rate(820, 824, 994)%%MC / Visa/ Discover NetworkNon-PIN Debit Discount Rate(880, 864, 978)%%MC / V/ Discover Network Non-Qual CreditTrans Fee(621,622,625,626) (721,722) MC / V/ Discover Network Non-Qual Non-PINDebit Trans Fee (150,151, 154, 155) (795,796) * Fees do not apply if Bundled Debit is chosen*MC / V/ Discover Ntwk Auth & Return Trans Fee(10A, 10D) (002, 006) (131, 135) (10J, 016, 788) American Express OnePoint Transaction Fee * Fees do not apply if Bundled Debit is chosenNon-Qual Surcharge Fee(30D, 20N)(excluding interchange pass-through fees, see Section 18.1)Applies to Non-qualified MC, Visa, Discover Network,Amer. Express Credit, and/or Non-PIN Debit Trans.0.00%**Retail and Restaurant merchants will be charged an additional 0.30% for non-swiped American Express transactions.Additional .40% applies for any Charge on a Card issued outside the U.S. except MCC 7032, 8211, 8220, and 8351 and Non U.S. Prepaid/Gift card transactions.Gift Card / Prepaid card transactions 1.95% or Supermarket Prepaid fee .20 / transaction.( 8 ) T E L E C H E C K R AT E S , S E R V I C E F E E S , A N D S E T U P I N F O R M AT I O NT E L E C H E C K B I L L T O I N F O R M AT I O NFirst / Last Contact Name:Your Head Office/Bill To Name:Phone Number:Tina MeadSuite #Address:2835 Northpoint Blvd(888) 758 - 0585City:State:Zip:Your Fax Phone:HixsonTN37343(423) 242-2751 TeleCheck Auto Settle Time: hh ET (Must be at least 1 hour after Card Auto Settle Time)T E L E C H E C K R E P O R T I N F O R M AT I O NFunding Report: Bill To LocationDelivery Method: E-Mail Fax US MailExisting Subscriber No.:Contact Name:Contact Telephone #:Report Fax #:Report E-Mail Address:Batch Closing Options: amFormat: CSV (E-Mail only) pm PDFT E L E C H E C K B A N K I N G I N F O R M AT I O NFunding: Per Bill To Per LocationACH Credits to TeleCheckby Subscriber (For Invoice Payment):Debits/ Credits (Settlement) to Subscriberby TeleCheck and/or Franking Information:ABA Transit #:Account #: Same as above or Same as above orABA Transit #:Account #:Special Instructions which are part of this Agreement:Please note on separate funding check the designated TeleCheck Service. A separate funding check for TeleCheck Services is NOT required UNLESSMerchant will be using different banking account(s) for TeleCheck Services.Client Initials

MERCHANTP R O C E S S I N G A P P L I C AT I O N A N D A G R E E M E N TPBDBA Name:880000000106Global Table Fee #:(Page 4 of 6)1 ofLoc.( 8 ) T E L E C H E C K R AT E S , S E R V I C E F E E S , A N D S E T U P I N F O R M AT I O N(cont’d)TeleCheck Services, Inc.P.O. Box 4514Houston, TX 77210-45141-800-366-1054WARRANTYSet-Up Fees:150.00 Add’l Location(s): @100.00 ea.No. of Physical Locations: 1st Location: @ ECA Lockbox ICA CBPSM PaperCheck Cashing Mail OrderTotal Set-Up Fee: CODAverage Check Size Monthly Check / Call Volume Inquiry Rate%Transaction Fee%%%%%%TotalSet-Up Fees% ( 150 add’l fee per product) One Rate Monthly Minimum CROC / Voice Auth Fee Statement Processing Fee Set-Up FeeDecember Risk SurchargeWarranty Maximum% % Face Amt. Face Amt. %(see TRS Services Section 9)Other:VERIFICATION %% %% Face Amt. 100 Personal 750 Gov 750 Corp Face Amt. Order Confirmation NoticeTRS Collections % Face Amt. TRS TRS TRS TRS TRS TRS TRS TRS LockboxLockbox Pro21 CBPSM PaperCheck Cashing eDepositPaper Only ECA ICA Average Check Size Monthly Check / Call Volume Transaction Fee ( 150 add’l fee per product) One Rate Monthly Minimum CROC / Voice Auth Fee Statement Processing Fee TotalSet-Up FeesSet-Up Fee CK21 Max Dollar Amount (see TRS Services Section 9)Other: Order Confirmation NoticeTRS Collections TRS TRSPaper Only TRS TRS TRS TRS TRS TRS See TeleCheck / TRS Agreement for definitions, warranties, and any additional fees.Note: See Section 1.38 “Damages” of the TeleCheck / TRS Agreement for early termination fees / liquidated damages.STMS(TCK)1505OrthoPBCorpFee1511(ia)( 9 ) T R S S E R V I C E S A N D R E C O V E R Y R AT E ECA Verification with TRS% of Item Amt. Recovered Retained by TRS: 20%Amt. of Return Item Fee Retained by TRS: 100% TRS for Warranty (Non-Compliance Items)% of Item Amt. Recovered Retained by TRS: 20%Amt. of Return Item Fee Retained by TRS: 100%NOTE: Stop payment checks due to disputes over goods or services must be returned to Subscriber for resolution. TRS Other (including Paper Verification)% of Item Amt. Recovered Retained by TRS: 20%Amt. of Return Item Fee Retained by TRS: 100%Bank Auth: Yes No Remittance Frequency: MonthlyClient Initials

MERCHANTP R O C E S S I N G A P P L I C AT I O N A N D A G R E E M E N TPBDBA Name:1 ofLoc.( 1 0 ) P AY M E N T E S S E N T I A L SSTMS(TCK)1505(Page 5 of 6)OrthoPBCorpFee1511(ia)Payment Essentials Type: Web.comNOTE: 3 Domain Names are required if website is chosen. (Limit 31 characters per line)Domain Name #1: Suffix Requested: .com .net .orgPick a Template:Domain Name #2: Suffix Requested: .com .net .orgDomain Name #3: Suffix Requested: .com .net .org Same as Contact Information in Tell Us About Your Business Section or provide:First/Last Contact NameContact PhoneContact E-Mail AddressC L I E N T I N F O R M AT I O N Same as Tell Us About Your Business Section or provide:First/Last Contact NameContact PhoneContact E-Mail Address Same as Tell Us About Your Business Section or provide:Shipping Address:City: Same as Contact Name or Provide Reporting Contact NameDelivery Method: Ground 2nd DayState:Zip: Same as Contact E-Mail Address or Provide Reporting E-Mail Address Next Day Air( 11 ) G I F T C A R D S E T U PPayment EssentialsGift Card To GoStandardDescription 100 500Custom 1000Gift Card To GoStandard Order 100 250 500G I F T CA R D TO G O P R I C I N G S C H E D U L ESeq. Code Per Item CostTOTALDescriptionQty.Gift Cards To Go 1000Qty.Transaction FeeCustom OrderSeq. Code Per Item Cost 1000TOTALG66-G71TOTAL SETUP COST:DescriptionS TA N DA R D P R I C I N G S C H E D U L ETOTALDescriptionQty.Seq. Code Per Item CostStandard CardsQty.Transaction FeeStandard CarriersPer LocationTOTALG66-G71EnvelopesGift Card Setup FeeSeq. Code Per Item CostG74G34TOTAL SETUP COST:DescriptionC U S TO M P R I C I N G S C H E D U L ETOTALDescriptionQty.Seq. Code Per Item CostCustom CardsQty.Transaction FeeCustom CarriersPer LocationG34TOTALG66-G71Color & Image Setup FeeGift Card Setup FeeSeq. Code Per Item CostPer OrderGraphic Design AssistanceG33G40TOTAL SETUP COST:M A R K E T I N G & P R O M O T I O N A L M AT E R I A L SDescriptionSequenceCodePartCodeQty.Per Item MNG5MNG6Acrylic Stand w/BoxAcrylic Standw/o BoxInsert PosterInsert Poster StandardG35MNRQG48MNRPSingle J Hook RackTable TentTable Tent Acrylic StandG30MNRRTable Tent PosterG30Insert Poster CustomG61Welcome KitG77Door DecalG36Qty.Per Item CostTOTALMNRHTOTAL COST:G I F T C A R D T O G O & S TA N DA R D D E S I G N I N F O R M AT I O NL1FRONT OF CARD LANGUAGE: Maximum 30 characters per line. 1 - 4 lines (except for Stripe card design) Use lower and/or upper case letters & spacing where desired. Text will be printed on the cards exactly as provided hereunless noted in the Comments section. TEXT IN ALL CAPS Text in Upper and Lower CaseGift Card To Go &Standard Card Design Code:L2L3L4Gift Card To Go &Standard Card Font Color:Front of Card Font:C U S T O M C A R D D E S I G N I N F O R M AT I O N Artwork to be provided in electronic format and compliant with specifications set in Custom Card Artwork Requirements. Send artwork to GiftCardArt@firstdata.com. Concepts or artwork elements to be provided. Send concepts to GiftCardArt@firstdata.com.C U S TO M P RO O F E X C H A N G E E-Mail proof. E-Mail address for proof approval: No E-Mail available. Proof will be sent Next Day Air to Client address. Cost will be passed through to Client.Client Initials

M E R C H A N T P R O C E S S I N G A P P L I C AT I O N A N D AG R E E M E N TPBDBA Name:(Page 6 of 6)1 ofLoc.( 1 1 ) G I F T C A R D S E T U P (cont’d)B AC K O F C A R D L A N G UAG E S E L E C T I O NGIFT CARD TO GO BACK OF CARD LANGUAGEThank you very much for your business. We look forward to seeing you again.BACK OF CARD LANGUAGEStandard back of card language isavailable on standard or custom cards. Thank you very much for your business. We look forward to seeing you again. Thank you very much for your business. We look forward to seeing you again.Muchas Gracias por su negocio. Esperamos la oportunidad de servirle nuevamente. Blank (except for card number)CUSTOM CARD ONLY:BACK OF CARD LANGUAGENote: Custom card back of card languageis only available on custom cards.Please note: It is advised that you seek legal advice for custom back of card language. YES Custom back of card language is to be forwarded to GiftCardArt@firstdata.com.Back of card artwork is in grey scale only.If custom card language not provided, standard back of card language will be printed:“Thank you very much for your business. We look forward to seeing you again.”CARD CARRIER SELECTIONGIFT CARD TO GOJ Hook Carrier Design:Note: Gift Card to Go carrier design defaults to J Hook and cannot be changed.STANDARD / CUSTOM CARRIER STYLE FoldingSTANDARD / CUSTOM CARRIER DESIGNNote: Sleeve pocket is not able to be customized. J Hook Sleeve PocketStandard Carrier:Custom Carrier to match Standard Card Design Code:Custom Carrier – Provide custom artwork to GiftCardArt@firstdata.com.Envelopes Ordered (G74)( 12 ) A G R E E M E N T A P P R O V A LThe statements made in this Merchant Processing Application and Agreement are true. Client acknowledges having received and read a copy of the Interchange Schedule (for card processing services),Program Guide (which includes terms and conditions for each of the services, Operating Procedures, Third Party Agreements and a Confirmation Page), and Merchant Processing Application (consisting ofSections 1-14), as modified from time to time in accordance with the provisions of this Agreement, and agrees to be bound by all provisions as printed therein. Client hereby consents to receiving commercialelectronic mail messages from us or our Affiliates from time to time. Client further agrees that Client will not accept more than 20% of its card transactions via mail, telephone or Internet order. However, ifyour Application is approved based upon contrary information stated in the Provide More Business Data section above, you are authorized to accept transactions in accordance with the percentages indicatedin that Section. This signature page also serves as the signature page to the Equipment Lease Agreement, TeleCheck / TRS Services Agreement, and the American Express Card Acceptance Agreementappearing in the Third Party Section of the Program Guide, if selected, the undersigned Client being the “Lessee” for purposes of such Equipment Lease Agreement, TeleCheck / TRS Services Agreement,and /or “You” and “Your” for the purposes of the American Express Card Acceptance Agreement.By signing below, I represent that I have read and am authorized to sign and submit this application for the above entity which agrees to be bound by the American Express Card Acceptance Agreement(“Agreement”), and that all information provided herein is true, complete, and accurate. I authorize First Data Merchant Services Corporation and American Express Travel Related Services Company, Inc. (“AXP”)and AXP’s agents and Affiliates to verify the information in this application and receive and exchange information about me personally, including by requesting reports from consumer reporting agencies, fromtime to time, and disclose such information to their agent, subcontractors, Affiliates and other parties for any purpose permitted by law. I authorize and direct First Data Merchant Services Corporation and AXPand AXP agents and Affiliates to inform me directly, or inform the entity above, about the contents of reports on me that they have requested from consumer reporting agencies. Such information will includethe name and address of the agency furnishing the report. I also authorize AXP to use the reports from consumer reporting agencies for marketing and administrative purposes. I am able to read and understand the English language. I understand that upon AXP’s approval of the application, the entity will be provided with the Agreement and materials welcoming it, either to AXP’s program for First Data MerchantServices Corporation to perform services for AXP, or to AXP’s standard Card acceptance program, which has different servicing terms (e.g., different speeds of pay). I understand that if the entity does notqualify for the First Data Merchant Services Corporation servicing program, that the entity may be enrolled in AXP’s standard Card acceptance program, and the entity may terminate the Agreement. By acceptingthe American Express Card for the purchase of goods and/or services, or otherwise indicating its intention to be bound, the entity agrees to be bound by the Agreement.By signing below, each of the undersigned authorizes us, our Affiliates and our third party subcontractors and/or agents to verify the information contained in this Application and to request and obtain fromany consumer reporting agency and other sources, including bank references, personal and business consumer reports and other information and to disclose such information amongst each other for anypurpose permitted by law. If the Application is approved, each of the undersigned also authorizes us, our Affiliates and our third party subcontractors and/or agents to obtain subsequent consumer reportsand other information from other sources, including bank references, in connection with the review, maintenance, updating, renewal or extension of the Agreement or for any other purpose permitted by lawand disclose such information amongst each other. Each of the undersigned furthermore agrees that all references, including banks and consumer reporting agencies, may release any and all personal andbusiness credit financial information to us, our Affiliates and our third party subcontractors and/or agents. Each of the undersigned authorizes us, our Affiliates and our third party subcontractors and/oragents to provide amongst each other the information contained in this Merchant Processing Application and Agreement and any information received subsequent thereto from all references, including banksand consumer reporting agencies for any purpose permitted by law. It is our policy to obtain certain information in order to verify your identity while processing your account application.As part of our approval, processing services, continuing fraud prevention and account review processes, the undersigned consents to the use of information gathered online or that you

Please sign at the Merchant Name line and complete the Merchant Name, Title, and Date. Page 10 - Merchant Services Agreement for SUB-MERCHANTS Please enter in Merchant Name. Page 11. Please enter in Merchant Name, Name, Title, Date, and Address. Please sign at Signature line. Please fax all pages to (888) 758-0587.