PREPAY POINT
MERCHANT APPLICATION FORM

CORPORATE AND PERSONAL INFORMATION
Company Name:
Hereinafter referred to as "Merchant"
Distributer:
DBA: (if any):
Email:
Contact Name:
Tel: ( )-
Address:

Fax: ( )-
 
Mobile: ( )-
Federal Tax ID:
Type of business Partnership Sole Proprietorship Corporation (LLC) Limited Liability Corp.
Date of Formation/Incorporation:
State of Incorporation:
Primary Owner's Name:
Social Sec No:
Home Address :
Date of Birth:
TERMINAL OPTIONS:
xPOS New  Terminal vPOS Virtual Terminal
CHARGES/FEES: In addition to any Application or Additional Fees in the Terms of Use, Merchant shall be charged:
Set-up Fee (one time): $ FREE From New Century Wireless, Inc. Monthly Access Fee: $
First Three months FREE (no contract required!)
Other: $
$18.99 per month or Free if sales are over $1000 per month
DECLARATION, ACKNOWLEDGEMENT AND AGREEMENT TO TERMS OF USE:

Merchant acknowledges and agrees that this Merchant Application Form (“Application Form”) is an application for “Services”, as further described in VIAONE’s Merchant Services Terms of Use (“Terms of Use”) provided by Via One Technologies, Inc. (“VIAONE”). VIAONE in its sole discretion shall determine whether to accept this application and provide Merchant with such Services. In the event that VIAONE accepts this Application and agrees to provide Merchant with such Services, VIAONE’s acceptance of this Application and agreement to provide Services shall be conditioned upon Merchants complete and strict compliance with the Terms of Use. As such, in the event that this Application is accepted by VIAONE, Merchant shall be bound by the terms and conditions of the Terms of Use, including all amendments to such Terms of Use made by VIAONE. Merchant authorizes VIAONE to obtain personal and company credit reports from credit bureaus and or verify information provided in this Application Form. Merchant also represents that Merchant is not a party to any agreement that would prevent Merchant from obtaining Services, or doing business with Via One Technologies or its partners. In signing below, signor represents and warrants that all information contained in this Application Form is true and correct and that he/she is a duly authorized representative of Merchant, and has the authority to sign this Agreement and bind Merchant as is noted herein and in the Terms of Use.
 Print Name:________________________________________ Signature:______________________________________________Date:___________________

ACCEPTANCE AND MERCHANT SET-UP BY VIAONE (to be filled in by VIAONE only):
E- Partner PIN Security Deposit
     $__________
Re-Sale Certificate Set-up ___________
___/___/___

ViaOne hereby accepts Merchant Application form and agrees to provide Merchant with Services in accordance with the Terms of Use.

Signed:_________________________________Date:__________________

Name: _________________________________ Title:__________________

AUTOMATED CLEARING HOUSE (“ACH”) AUTHORIZATION AGREEMENT
Subject to (i) the terms set forth in the Merchant Application Form dated as of , 2007, submitted by (“Merchant”) (ii) VIAONE’s Merchant Services Terms of Use, (iii) the Operating Rules of the National Automated Clearing House Association, and (iv) applicable federal regulations governing Automated Clearing House (“ACH”) transactions, I (we) do hereby authorize Via One Technologies, Inc., and any partner or subsidiary of Via One Technologies, Inc (collectively referred to as “VIAONE” for the purposes of this ACH Authorization) to initiate debit and credit entries to the account specified below for obligations owing from time to time resulting from the transactions described in the Merchant Services Terms of Use.

I certify under penalty of perjury that am a duly authorized as a check signer on the account identified below and am authorized to provide all relevant consents and representations contained in this ACH Authorization, as evidenced by my signature below.
Financial Institution Name: Branch:
Address:
City: State: Zip:
Routing Number: Account Number:
Checking Savings

In the event that VIAONE incurs any charges due to failure of an ACH debit to properly process to Merchant’s account specified above (after several attempts by VIAONE), or in the event that such account does not have sufficient funds to permit the ACH debit to go through, I (we) hereby grant VIAONE the authority to debit the account for all such charges and expenses incurred together with a $25 administrative fee per failed ACH. This authorization is to remain in full force and effect until VIAONE has received written notification from me or another duly authorized representative of Merchant of it’s the termination hereof in such time and in such manner as to afford VIAONE and its partners, a reasonable opportunity to act on it.

Name on Account/Merchant: Business Personal
Address:
City: State: Zip:

Signature:_____________________________________________

Name (Print):___________________________________________  

Date:_____/______/______

 

 

Please attach a voided check from the account specified above
(Starter checks will not be accepted)

 

 

UNIFORM SALES & USE TAX CERTIFICATE_MULTI-JURISDICTION

The below-listed states have indicated that this form of certificate is acceptable, subject to notes

on pages 2-4. The Issuer ant the recipient have the responsibility of determining the proper use

of this certificate under applicable laws in each state, as these may change from time to time.

Issued to Seller:   Via One Technologies

Address: 525 Broadway 5th Floor, New York, NY 10012

I Certify that:                                                   

Name of Firm (Buyer):

Address:

             

             

is engaged as a registered

Wholesaler

Retailer

Manufacturer

Seller (California)

Leaser (see notes on pages 2-4)

Other (specify)

and is registered with the below listed states and cities within which your firm would deliver purchases to us

and that any such purchases are for wholesale, resale, ingredients or components of a new product to be

resold, leased, or rented in the normal course of our business. We are in the business of wholesaling,

retailing, manufacturing, leasing (renting) the following:

 

Description of Business:

General description of tangible property or taxable services to be purchases from  the seller: ___________________

 

______________________________________________________________________________________________________________________________________

 

State of Registration:

Seller's Permit or ID number or Purchaser:

 

I further certify that if any property so purchased tax fee is used or consumed by the firm as to make it subject to a Sales or Use Tax we will pay the tax due direct to the proper taxing authority when state law so provides or inform the seller for added tax billing. This certificate shall be part of each order which we may hereafter give to you, unless otherwise specified, and shall be valid until canceled by us in writing or revoked by the city or state.

 

Authorized Signature: ___________________________________________________________________________________________________________________

                                                                                                                                          (Owner, Partner or Corporate Officer)

 

Title:________________________________________________________________________________

 

Date:_______________________________________________________________________________

 
Please either print and fill in information or fill out this application online Completely.
1.Print the page
2.Sign the paper copy it in the appropriate places and confirm that it is filled completely
3.Fax it in to New Century Wireless, Inc. at 1-708-301-8735.
We can not accept applications that are unsigned.
If you have any questions please call us at (708) 401-3449

Merchant Terminal Agreement

 

MERCHANT INFORMATION

Business Name:

Business Owner Name:

Business Phone Number:

Owner Mobile PhoneNumber:

 

TERMINAL INFORMATION

Monthly Usage Fee:

$18.99*

 

This Merchant Terminal Agreement (“Terminal Agreement”), dated this day of , , by

and between the party named above (“Merchant”) and Via One Technologies, Inc, a New Jersey company

(“VIAONE”) outlines the terms and conditions by which VIAONE will provide Merchant a Terminal (as noted

above) for the purpose of purchasing products and services from VIAONE.

WHEREAS Merchant and VIAONE have signed, or are signing contemporaneously herewith, a Merchant

Agreement (“Merchant Agreement”) that enables Merchant to purchase for the purpose of resale certain

products and services provided by VIAONE,

WHEREAS Merchant desires to obtain and VIAONE desires to provide Merchant with a terminal for use in

conjunction with Merchant Agreement and in accordance with the terms and conditions of this Terminal

Agreement.

NOW THEREFORE for the foregoing premises and consideration, the receipt and sufficiency of which are

hereby acknowledged, the parties intending to be legally bound, agree as follows:

1. After signing this Terminal Agreement, VIAONE shall provide Merchant with a Terminal model and make

of VIAONE’s choice. Such Terminal, unless otherwise agreed in writing by VIAONE, shall only be used

for the purpose of procuring products and services from VIAONE in accordance with the Merchant

Agreement.

2. Merchant shall not reprogram, add, alter, in any way modify, or change the software code or hardware of

the Terminal at any time.

3. The monthly cost of using the Terminal shall be the Usage Fee noted above (“Usage Fee”).

Notwithstanding the foregoing, VIAONE hereby agrees to waive such Usage Fee for each month during

the term of this Terminal Agreement where the Merchant’s aggregate PIN purchases under the Merchant

Agreement exceed $1,000.00. In the event that Merchant’s monthly purchases are below $1,000.00

 

Page 2 of 3

Merchant Terminal Agreement – S – 1 Merchant __________ VIAONE ______

 

under such Merchant Agreement, Merchant hereby permits VIAONE to ACH Merchant’s bank account for

such Usage Fee using the ACH authorization form provided to VIAONE under the Merchant Agreement

or herewith.

4. Unless the parties otherwise agree in writing, such Terminal shall at all times remain the property of

VIAONE. Merchant shall be required to return the Terminal to VIAONE in Good Working Order within 10

calendar days of the termination of this Terminal Agreement, or receipt of a demand notice from VIAONE

for its return. In the event that Merchant fails to return the Terminal within such 10 day period, or such

Terminal is not in Good Working Order when returned, then Merchant shall be required to pay VIAONE

the Terminal Cost (as noted above) for such Terminal. VIAONE shall be permitted, in such event, to ACH

Merchant’s account for such fee. In such event, upon receipt of funds by VIAONE, the Merchant shall

then own the Terminal.

For the sake of clarity and not limitation, “Good Working Order” shall mean that such Terminal is in similar

condition to its condition when Merchant initially received the Terminal with the exception of reasonable

marks of wear and tear from daily use. Additionally, the Terminal shall not have any parts missing or

broken and/or the Terminal shall not have been altered, defaced, reprogrammed and must be in a

condition where VIAONE could reasonably present such Terminal to another Merchant for daily use upon

receipt.

5. LIMITATION OF LIABILITY AND NO WARRANTIES. THE TERMINAL PROVIDED BY VIAONE IS

PROVIDED “AS IS” WITHOUT ANY WARRANTIES OF ANY KIND WHETHER EXPRESS OR IMPLIED.

VIAONE EXPRESSLY DISCLAIMS ALL IMPLIED WARRANTIES OF MERCHANTABILITY, FITNESS

FOR A PARTICULAR PURPOSE, TITLE, AND NON-INFRINGEMENT OF THIRD PARTY RIGHTS.

MERCHANT ACKNOWLEDGES AND AGREES THAT VIAONE MAKES NO REPRESENTATIONS AS

TO THE REASONABLENESS, APPROPRIATENESS, QUALITY OR FUNCTIONALITY OF PRODUCTS

OF THE TERMINAL. IN NO EVENT WILL VIAONE BE LIABLE TO THE MERCHANT OR ANY OTHER

PARTY FOR ANY SPECIAL, INCIDENTAL, INDIRECT OR CONSEQUENTIAL DAMAGES OF ANY

KIND INCLUDING THOSE RESULTING FROM INTERRUPTION OF USE, LOSS OR CORRUPTION OF

DATA, VIRUSES, OR LOST PROFITS, ARISING FROM OR RELATED TO THIS TERMINAL

AGREEMENT, THE USE OR FAILURE OF THE TERMINAL WHETHER OR NOT THE PARTY

SUFFERING LOSSES HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGE.

THE TOTAL CUMULATIVE LIABILITY FOR VIAONE IN CONNECTION WITH THIS TERMINAL

AGREEMENT AND/OR THE USE OR FAILURE OF THE TERMINAL, WHETHER SUCH LIABILITY IS

ASSERTED IN CONTRACT, TORT OR ANY OTHER THEORY OF LAW, SHALL BE LIMITED TO

REPLACING OR REPAIRING ANY TERMINAL PROVIDED HEREUNDER.

6. This Terminal Agreement shall become effective when signed by VIAONE and Merchant. Once signed

by both parties, this Terminal Agreement shall remain in effect until it is terminated by either party by

providing the other with notice of its desire to terminate. Such notice shall be effective from the moment it

is received by the recipient. Notwithstanding the foregoing, this Terminal Agreement shall automatically

terminate upon termination of the Merchant Agreement.

7. This Terminal Agreement shall be interpreted in accordance with the laws of New York without regard to

the conflict of laws principles thereof. Any action under this Terminal Agreement must be undertaken in

the city of New York, NY.

8. Merchant may not assign this Terminal Agreement without the written permission of VIAONE. VIAONE

may assign this Terminal Agreement by providing notice to the Merchant. The provisions of this Terminal

Agreement shall be binding upon and inure to the benefit of the parties hereto and to their respective

successors and permitted assigns.

 

Page 3 of 3

Merchant Terminal Agreement – S – 1 Merchant __________ VIAONE ______

9. Any notice required to be given hereunder shall be in writing and delivered by a nationally recognized

courier service to the address located on the first page or in the recitals of this Terminal Agreement,

unless such address is altered by notice in which case delivery shall be made to such new address.

10. The parties signing below acknowledge and agree that that they have the full right and authority to sign

this Terminal Agreement on behalf of the companies below.

By Via One Technologies, Inc:

 

By: ________________________________________ Date_______________

 

Name: ________________________________________

 

Title: ________________________________________

 

By Merchant:

 

By: ________________________________________ Date_______________

 

Name: ________________________________________

 

Title: ________________________________________

 

MERCHANT OWNER PERMISSION AND ACKNOWLEDGEMENT

 

I ____________________________________ am the owner of the Merchant business identified in this Terminal Agreement. I

hereby permit VIAONE, or its affiliates to conduct background and/or credit checks on me and my business to qualify my

business for the Merchant Terminal Program reflected in this Terminal Agreement. I understand that VIAONE may refuse to

enroll my company (the Merchant) in this program in the event that our credit rating does not meet the credit requirements of

VIAONE in implementing this program. I also acknowledge and agree that in the event that VIAONE signs the Terminal

Agreement and VIAONE is unable to collect any amount of money due from the Merchant under this Terminal Agreement, I

will be personally liable for such obligations to VIAONE. I also acknowledge and agree that my personal guarantee is a

material inducement for VIAONE to enter into this Agreement, and that as the owner of Merchant business, sufficient

consideration is provided to me personally to obligate me with regard to the debt obligations of the Merchant herein.

 

By: _________________________________ Address: __________________________________

 

Name: _________________________________ __________________________________

 

Social Sec. No: _________________________________ __________________________________

 

Phone No: _________________________________ __________________________________