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<br />Primar Owner/Officer Name: Carrie Co fer Other Owner/Officer Name:
<br />
<br />Home Address: __~ _... _ _ __.__.___. .. _. ._._ _. .
<br />Home Address:
<br />
<br />it ,State, Zi :North Olmsted OH 44070 ~~_ ~.___ City, State, Z~~
<br />
<br />,_Home Phone: ---_~_____..__ _ _ ___.
<br />Home Phone:
<br />
<br />~ Years There: 0 _..v_ ........... .._..._ .
<br />---
<br />Years There:
<br />
<br />Own or Rent? Own or Rent? -w_._,.__.__~ ,~,,_,~_~.______ _
<br />
<br />-mail Address: co rc north-olmsted.com E-mail Address:
<br />
<br />ate of Birth: Date of Birth:
<br />Social Securit Number: xxx-xx-xxxx Social Secunty Number:
<br />- ..
<br />I/We hereby guarantee to Global Direct and Member, their successors and assigns, the full, prompt, and complete performance of Merchant and alf of
<br />Merchant's obligations under the Card Services Agreement, including but not limited to all monetary obligations arising out of Merchant's performance or non-
<br />performance under the Card Services Agreement, whether arising before or after termination of the Card Services Agreement. This guaranty shall not be
<br />discharged or otherwise affected by any waiver, indulgence, compromise, settlement, extension of credit, or variation of terms of the Card Services Agreement
<br />' made by or agreed to by Gobal Direct, Member, and/or Merchant. I/We hereby waive any notice of acceptance of this guaranty, notice of nonpayment or
<br />nonperformance of any provision of the Card Services Agreement by Merchant, and all other notices or demands regarding the Card Services Agreement.
<br />', I/Vi/e agree to promptly Qrovide to Global Direct, and Member any information requested by any of them from time to time concerning my/our financial
<br />condition(s), business history, business relationships, and employment information. I/We have read, understand, and agree to be bound by the Card Services
<br />Terms and Conditions. document provided to Merchant and those terms and c~nditinnc rnnrainari in rr,~~ nnor~r,~„+ nn.,r,.~~~.,.,
<br />Signature of Guonantor
<br />,an individual Name (printed): Carrie Copfer
<br />By signing bebw, I represent that I have read and am authorized to sign and submit this application on behalf of the entity above and all information I have
<br />Provided herein is true, complete, and accurate. I authorize American Express Travel Related Services Company, Inc. ("American Express") to verify the
<br />information in this application and receive and exchange information about me personally, including by requesting reports from consumer reporting agencies.
<br />I authorize and direct American Express to inform me directly, or through the entity above, of reports about me that American Express has requested from
<br />consumer reporting agencies. Such information will include the name and address of the agency fumishin~ the report. I understand that upon American
<br />Express' approval of the entity indicated above to accept the American Express Card, the terms and conditions for American Express® Card Acceptance
<br />(`Terms and Conditions") will be sent to such entity along with a Welcome Letter. By accepting the American Express Card for the purchase of goods and/or
<br />services, or otherwise indicating its intention to be bound, the entity agrees to be bound by the Tenns and Conditions
<br />Merchant's Signature:
<br />Name (printed):
<br />Title:
<br />Date:
<br />1. Are you going to use a POS terminal, software, or gateway application from Global Payments? r Yes x No
<br />(If Yes, go to Question #4 & select "No". If No, go to Question #2.)
<br />2. Are you using a "dial-up" terminal? r Yes x No
<br />(If yes, go to Question #4 & select "No". If No, go to question #3.)
<br />3. a) What third party software company/vendor did you purchase your POS Application from? Future POS -Cutting Edae Solutions
<br />b) What is the name of the third party software? Future POS - Cutting Edae Solutions Version #? 4.1 P I
<br />_ c) Do your transactions process through any other third parties, web hosting companies or gateways? r Yes x No
<br />If yes, who is it?
<br />(Please continue to Question #4)
<br />4. a) Do you or your vendor receive, pass, transmit or store the full cardholder number, electronically? x Yes '~ No
<br />b) If yes, where is card data stored? x Merchant n Third Party Only r Both Merchant & Third Party r GAA Export Only
<br />b1.) Are you or your vendor PCI/DSS (Payment Card Industry/Data Security Standard) compliant? ~ Yes x No
<br />b2.) What is the name of your Qualified Security Assessor?
<br />b3.) Date of compliance: Date of last scan:
<br />5. Have you ever experienced an account data compromise? r- Yes x No If yes, when?
<br />""" Card Association requirements dictate it is prohibited to store track data in any circumstance. Further, it is recommended that no merchant or a
<br />merchant's third party vendor store cardholder data. If you or your vendor store data, you or your vendor are required to be PCI DSS compliant.
<br />Failure to adhere to these requirements may result in fines or loss of card acceptance. ""*
<br />8788430056479 Cartwright
<br />',
<br />10 BumeR Court, Suite 300 Durango, Colorado, 81301 (800) 846-4472 www.MercuryPay.com
<br />Mercury Payment Systems, Inc. is a registered ISO and MSP of HSBC Bank, USA, National Association, Buffalo, NY
<br />Rev.04/08 MPS
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