Merchant Signup Form

* denotes a required field

Basic Merchant Information

  • Paygrip

Business Names

Merchant Profile

  • Do you currently process credit cards
  • Has Merchant or any associated principal disclosed below filed bankruptcy or been subject to any involuntary bankruptcy

Financial Information

  • eCommerce

Member Bank Information

Deutsche Bank AG,
c/o Deutsche Card Services GmbH
Kaltenbornweg 1-3, 50679 Cologne, Germany
+49 221 99577 777
support.deucs@db.com

Important Member Bank Responsibilities

  1. A Visa Member is the only entity approved to extend acceptance of Visa products directly to a merchant.
  2. A Visa Member must be a principal (signer) to the Merchant Agreement.
  3. The Visa Member is responsible for educating Merchants on pertinent Visa Operating Regulations with which Merchants must comply.
  4. The Visa Member is responsible for and must provide settlement funds to the Merchant.
  5. The Visa Member is responsible for all funds held in reserve that are derived from the settlement.

Important Merchant Responsibilities

  1. Merchant must ensure compliance with cardholder data security and storage requirements.
  2. Merchant must maintain fraud and chargebacks below thresholds.
  3. Merchant must review and understand the terms of the Merchant Agreement.
  4. Merchant must comply with Visa Operating Regulations.
  5. The responsibilities listed above do not supersede terms of the Merchant Agreement and are provided to ensure the merchant understands these specific responsibilities.

Cardholder Storage Compliance & Service Provider

***** Payment Card Industry Data Security Standards ("PCI DSS") and card association rules prohibit storage of track data under any circumstances. If you or your Point of Sale ("POS") system pass, transmit, store or receive full cardholder's data, then the POS software must be Payment Application Data Security Standard ("PA DSS") compliant or you (merchant) must validate PCI DSS compliance (see 31(b) below and questions #3 and #4 must be completed). If you use a payment gateway, they must be PCI DSS compliant. *****

  • Have you ever experienced an Account Data Compromise ("ADC")
  • Have you validated PCI DSS compliance
    If yes, go to #1(b); If no, go to #2
  • Are you using a "dial-up" or Touch Tone Capture ("TTC")
  • Do you or your Service Provider(s) receive, pass, transmit, or store the Full Cardholder Number ("FCN"), electronically
    3. Do your transactions process through any other Service Provider (i.e., web hosting companies, gateways, corporate offices)

Owner(s) or Officer(s)

(Individual ownership must be greater than or equal to 50%)

#1 - Owner or officer*

#2 - Owner or officer

ISO Representative

I hereby verify that this application has been fully completed by merchant applicant and that I have physically inspected 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.

Verified and inspected by:
Representative Print Name: Judson Smith / Paygrip LLC
Date: 13/02/2014
EVO IS A REGISTERED SERVICEMARK OF EVO MERCHANT SERVICES, LLC

Rate Schedule

  • By checking this box you agree that you have read, understand, and accept the Rate Schedule as outlined here Merchant Rate Schedule

Debit/Credit Authorization

Merchant authorizes any part to the Agreement to present Automated Clearing House credits, Automated Clearing House debits, wire transfers, or depository transfer checks to and from the following account and to and from any other account for which any such parties are authorized to perform such functions under the Merchant Processing Agreement, for the purposes set fourth in the Merchant Processing Agreement. This authorization extends to such entries in said account concerning lease, rental or purchase agreements for POS terminals and/or accompanying equipment and/or check guarantee fees and amounts due for supplies and materials. This Automated Clearing House authorization cannot be revoked until all Merchant obligations under this Agreement are satisfied, and Merchant gives written notice of revocation as required by this Agreement.

INVESTIGATIVE CONSUMER REPORT: An investigative or consumer report may be made in connection with application. MERCHANT authorizes ANY PARTY TO THE AGREEMENT or any of their agents to investigate the references provided or any other statements or data obtained from MERCHANT, and from any of the undersigned personal guarantor(s), or from any other person or entity with any financial obligations under this Agreement. You have a right, upon written request, to a complete and accurate disclosure of the nature and scope of the investigation requested.

BANK CARD
AMEX

Each person certifies that the average ticket size and sales volume indicated is accurate and agrees that any transaction or monthly volume that exceeds either of the above amounts could result in delayed and/or withed settlement of funds. Also see paragraphs 4.C, 9 and 13.B of the MERCHANT Processing Agreement regarding suspension and termination of MERCHANT. *Highest ticket for informational purposes only.

IMPORTANT NOTICE: All information contained in this application was completed or supplied by all contracting parties. EVO and BANK shall not be responsible for any change in printed terms unless specifically agreed to in writing by an officer of EVO and BANK. By signing on either the original or a facsimile you are agreeing to the provisions stated within the Terms and Conditions of the Merchant Processing Agreement and the Merchant Application on the reverse side, and you are acknowledging that you have carefully read each of those provisions before signing.

FOR ALL CORPORATIONS CORP. RESOLUTION - This indicated officer(s) identified in numbers 1 and/or 2 below have the authorization to execute the MERCHANT Processing Agreement on behalf on the herewithin named corporation. MERCHANT UNDERSTANDS THAT THIS AGREEMENT SHALL NOT TAKE EFFECT UNTIL MERCHANT HAS BEEN APPROVED BY BANK AND A MERCHANT NUMBERS IS ISSUED.

Personal Guaranty (No titles)

As a primary inducement to EVO and Bank to enter into this Agreement, the undersigned Guarantor(s), by signing this Agreement, jointly and severally, unconditionally and irrevocably, personally guarantee the continuing full and faithful performance and payment by Merchant of each of its duties and obligations to EVO and Bank under this Agreement or any other agreement currently in effect or in the future entered into between Merchant or its principals and EVO and Bank, as such agreements not exist or are amended from time to time, with or without notice. Guarantor(s) understands further that EVO and Bank may proceed directly against Guarantor(s) without first exhausting their remedies against any other person or entity responsible to it or any security held by EVO and Bank or Merchant. Guarantor(s) waive trail by jury with respect to any litigating arising out of or relating to this personal guaranty. This guaranty will not be discharged or affected by the death of the undersigned, will bind all heirs, administrators, representatives and assigns and may be enforced by or for the benefit or any successor of EVO and Bank. Guarantor(s) understand that the inducement to EVO and Bank to enter into this agreement is consideration for the guaranty, and that this guaranty remains in full force and effect even if the Guarantor(s) receive no additional benefit from the guaranty.
AGREED AND ACCEPTED

Draw your signature

#1 From Application - Signature



#2 From Application - Signature



If Merchant submits a transaction hereunder, Merchant will be deemed to have accepted the Terms and Conditions of the Merchant Processing Agreement. For Merchants who have elected to accept the American Express Card, the submission of an American Express Card transaction will be deemed to be an acceptance of the American Express Card Acceptance Agreement and the above American Express provisions (located within the Merchant Rate Schedule).