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?• ._3.. "�'• '-r'r<` a '` rcIN <br /> - <br /> :h• 1�,?q,� 0Ija2noivll <br /> .ht5. :3-a:Tt :s.'� �"r s'��sa*si. .«:��. <br /> COMPANY PRESIDENT: Bob Solari(Board of County Commissioners) <br /> E <br /> SIDENTIALADDRESS IS PREFERRED,BUT IF NOT AVAILABLE BUSINESS ADDRESS IS ACCEPTABLE) <br /> REET ADDRESS 1801 27th Street1 <br /> CITY 11 Vero Beach STATE FL ZIP CODE 32960 <br /> COMPANY CFO: 11 <br /> E'REDENL ADDRESS IS PREFERRED,BUT IF NOT AVAILABLE BUSINESS ADDRESS IS ACCEPTABLE) <br /> RESS <br /> CITY =1 STATE Oe ZIP CODE <br /> IS THERE ANYONE NOT LISTED ABOVE WHO HAS THE AUTHORITY TO MAKE FINANCIAL DECISIONS OR CONTROL COMPANY POLICY ON BEHALF OF YOUR BUSINESS? <br /> ❑YES OWNER ADDENDUM REQUIRED(SALES REPRESENTATIVE WILL PROVIDE) NNO <br /> < ...,,. .. ^."•a °'<;ar'a;c«:».:-r,: s'.. . b,�'_ s l. <br /> s t„ ��f;+-y�:"'y'F:r-<::.,. a,,,,;�e s:€i• _F'... _ ., <br /> , <br /> >_ �-4.x �..:.�.».....S. :et :�:�:...,°' =:3',k':_>Fi,..\ __." �- •.2 n.�:±`s`r�. ".a`._ WN <a <br /> AUTHORIZED ADMINISTRATOR FOR PURPOSES OF ACCOUNT BOARDING AND IMPLEMENTATION MEANS AN OWNER,PARTNER,OFFICER,EMPLOYEE OR OTHER AGENT <br /> OF THE MERCHANT THAT HAS BEEN APPOINTED BY AN EXECUTIVE OF MERCHANT AND WHO IS DULLY AUTHORIZED TO PROVIDE INFORMATION AND EXECUTE <br /> DOCUMENTATION ON BEHALF OF AND RELATED TO MERCHANT IN ORDER TO FACILITATE THE INITIAL SET UP OF MERCHANTS'S ACCOUNT WITH CHASE PAYMENTECH. <br /> PER CHASE PAYMENTECH POLICY,AUTHORIZED ADMINISTRATORS ARE NOT PERMITTED TO MODIFY THE MERCHANT'S ACCOUNT WITH CHASE PAYMENTECH AFTER <br /> COMPLETION OF THE INITIAL SETUP OF MERCHANTS'S ACCOUNT SUCH CHANGES MUST BE MADE,BY AN EXECUTIVE OR FINANCIAL CONTACT,AS APPLICABLE AND AS <br /> THOSE ROLES ARE DEFINED BY MERCHANT <br /> NAME(please print) Bob Solari TITLE(please print) Board of County Commissioners <br /> TELEPHONE NUMBER 772-226-1440 EMAIL ADDRESS. bsolari@ircgov.com <br /> SIGNATURE 01.• DATE: July 12 2016 <br /> gg 111 <br /> 'iDih <br /> a � "s .. <br /> g. <br /> I,the undersigned,being an officer/principal of represent and warrant that the statements made on this document are correct and factual. JPMorgan Chase <br /> Bank, N.A ("Member") and Paymentech, LLC ("Paymentech" or "Chase Paymentech") are authorized to conduct any necessary investigation, including without <br /> limitation,authorization for a bank to release standard banking information. <br /> (Photocopy of signature below is valid for the release of information and will remain valid until the termination or expiration of the Merchant Agreement) <br /> NAME(please print) Bob Solari TITLE(please print) Board of County Commissioners <br /> SIGNATURE I DATE July 12, 2016 <br /> (IF THE SIGNER HAS NOT ALREADY PROVIDED IT ABOVE,A RESIDENTIAL ADDRESS IS PREFERRED, IF AVAILABLE (NO PO BOX OR PAID MAILBOX). IF NOT AVAILABLE <br /> BUSINESS ADDRESS IS ACCEPTABLE. <br /> STREET ADDRESS 180127th Street <br /> CITY Vero BeachSTATE FL ZIP CODE 32960 <br /> v... . ... x„:sx�, em .. ,mp- <br /> � <br /> A§ .'a L110.1,6Z :..:<:v_..L.si ,. C�',fi'e,r �4,. `s` "MMINIM. <br /> SUBMITTER NAME Invoice Cloud,Inc. <br /> *Note: Each Merchant is required to submit a W9 with this application, regardless if Paymentech will be utilizing the Submitter's TIN for IRS <br /> reporting purposes. .�y�OA1M/s8j•'• <br /> Attest,JetRey R.Smith,Cterk of o•J�`• .�A�F9 <br /> t VO• ' <br /> Circuit Couft and Comptrdlw <br /> APPROVED AS TO FORM *i <br /> AND LEQAL. SUFFICIENCY or. <br /> BYu Deputy Cleric ••?�'9,y• t; r ;0��: <br /> DYLAN Al2INGOLD �•'R:�'ERCa11NrE''✓ <br /> "WNTY AfT6RNEY ". <br /> Rev 11/15 <br /> Page 2 of 2 Paymentech Contract No.063576 <br />