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CHASE ®P Merchant Services•4 Northeastern Boulevard, Salem, NH 03079-1952 •www.chasepaymentech.com. <br /> Phone. (603)896-6000•Fax:(603)896-8715•Merchant-Services@ChasePaymentech.com <br /> Paymerttech - <br /> Addendum for Application for Credit Card Processing Service <br /> Agreement/New Division Request <br /> Date. 7/5/16 Company ID#- <br /> Projected Live Date. 10/5/16 <br /> -a•:r,r..:�;a,,,�y::"-kor ----mss+- --. -=• -..r^` <br /> ON�1..,CO,MPANY/CQNTAC;T:INFORM'A_TLON>Ya : - <br /> ON., <br /> Company Legal Name: Invoice Cloud, Inc <br /> Company Taxpayer ID#: 26 3972596 <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 /> l 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 /> z ze'b''IF.•1 yrs..C:c+:--e�X'r-. .:3. :Hs•:�,:'=i'�rs ',l. `^'a.."' i'ix:_-i;.� •,;�:- --`,' - _ <br /> . `.'2'y#;k.' ''f�-s`..zt''fi'• :_ �a.:a:Y:,E`>- �. gv'r' .v: eY: r•-r.�:••�"--nom <br /> S,EC,TIQN12xBU_SINESSU.NITS(ifdtfferentfcomsdtvtsionoame ; p' '- = y <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 /> � s='�`�"-S 'tc "y <br /> :� !a 2 �;�."•'.y� s•:.Y<; .?=�f?' SF <br /> SECTION 3.;;FUNDING�(if=ne.wbank/i� <br /> MIZE <br /> If funds should be deposited to an existing bank account please complete the fol lowing: <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 . lease complete the following: <br /> If USD or CAD, will this division utilize an existing Funds Transfer Instruction (FTI)?[:] Yes or [:)No If no,a new FTI will be created. <br /> If yes, provide FTI # (Section 9 does not need to be completed) <br /> 149 <br /> Rev11/18/10 1 NewDivisionSetup/cboo <br />