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CHASE C® Merchant services•4 Northeastern Boulevard,Salem,NH 03079-1952 •www chasepaymentech.com. <br /> Paymentech Phone.(603)896-6000•Fax:(603)896-8715.Merchant_Services@ChasePaymentech.com <br /> •Y Addendum for Application for Credit Card Processing Service <br /> Agreement/New Division Request <br /> Date 7/5/16 Company [D#- <br /> Projected Live Date 10/5/16 <br /> SECTION 1: COMPANY/CONTACT INFORMATION <br /> Company Legal Name Invoice Cloud, Inc <br /> Company Taxpayer ID#- <br /> Contact Name Robert Lapides Phone#- (781) 848-3733 EXT 223 <br /> Fax#- 877-256-8330 Email Address blapides@invoicecloud com <br /> Transactions processed for this new set up request belong to: <br /> Merchant whose company legal name is represented above <br /> OR <br /> County of Indian River Board of <br /> An Additional Company whose legal name is* County Commissioners and is a ❑ wholly-owned <br /> ❑ partially owned ® affiliate ❑ registered DBA or ❑ Other (explain. ) of the merchant noted above <br /> On behalf of Invoice Cloud Inc <br /> (Company Legal Name) <br /> I, Robert Lapides President, GUB Division <br /> (Print Name) (Title) <br /> verify that the account set-up information is accurate, that I have the authority to make such a request and <br /> thus, it should be used to set up an additional account for our company <br /> SECTION 2: BUSINESS-UNIT-:(if different from division name) <br /> Parent Business Unit (up to 30 bytes) Parent Bus Unit# <br /> Name (if applicable) (if applicable) <br /> Business Unit Name: County of Indian River BCC (up to 30 bytes) Business Unit#: <br /> SECTION 3: FUNDING.(if_new banking see section 9) <br /> If funds should be deposited to an existing bank account please complete the following: <br /> If USD or CAD,will funds be deposited into your existing Bank Account set up with Chase Paymentech? ❑Yes or ❑No <br /> If yes, Bank Account# (Section 9 does not need to be completed) <br /> If funds should be deposited to an existing funds transfer instruction please complete the following: <br /> If USD or CAD, will this division utilize an existing Funds Transfer Instruction (FTI)?❑Yes or ONO If no,a new FTI will be created- <br /> If yes, provide FTI # (Section 9 does not need to be completed) <br /> Rev11/18/10 1 NewDivisionSetup/cboo <br />