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CHASE CP 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
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<br /> Please check below if applicable:
<br /> ® Bill Payment(A Bill Payment transaction is a transaction for an ongoing service/billing cycle that is known and agreed upon in
<br /> advance by the merchant and cardholder i.e Membership or Insurance, etc.)
<br /> Do you stock product? ❑ Yes ® No Do you provide custom orders at time of sale? ❑ Yes ® No
<br /> Do you own the product at the time of sale? ® Yes ❑ No
<br /> Do you drop ship the product? ❑ Yes ® No If yes, what%
<br /> Are you filling your own merchandise orders? ® Yes ❑ No
<br /> If no, who is your fulfillment service bureau?
<br /> Fulfillment Contact: Phone#
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<br /> •- ;,,,�,:-.��tx,4,�X�,,,`L Y,�, ,',r'.(, 4;��.':.r:�;,� „ �, sco er)rM,RQA..(Manager/supervisor..-,=<one'iyhoassignswortc to.-MR;4s
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<br /> t.�N,O.�TLE�aTh�s�'conta�t�mayYdeceiveany.exceptiondocuments tFiat;may'need�to_bemailed:or faxed_;it••notpartici titin ,m;Char eback �;�°:
<br /> �Mana ement3this;will�be�the•default:con '#' " ' -� ' ' = -�•-._- ar;Y -p�-----9 :a 9,.,,,.�,,.;--,,r�:
<br /> tact;for C6'ar eback Mailin second;contacf.will.�not `�s� ��'p=� �v. '�- �'=~- ��
<br /> Location: ❑ Merchant ® Submitter ❑ Fulfillment (check one) If Submitter/Fulfillment, Name:
<br /> ❑ Mr ® Mrs ❑ Ms First Name Carolyn Last Name- Ambrose
<br /> Title. Administrative Assistant Phone#' 781-848-3733 Ext: 231
<br /> Fax#- 877-256-8330 Alternate Fax#
<br /> Email Address: Cambrose@invoicecloud com
<br /> Address. 30 Braintree Hill Office Park
<br /> City: Braintree State/Prov MA Zip/Postal Code 02184 Country: USA
<br /> Will this contact require access to Transaction History ❑ Report Center ❑ both ® ?
<br /> Account Masking for this contact? ® Yes ❑ NO
<br /> Does this contact have a Paymentech Online User ID? ❑Yes ®No If yes, provide User ID:
<br /> 1+�M�e�•q'•......•.�y ...A. :,��..li�. -a-�[Ls•:•. _ _ MSN
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<br /> Y Re wired for retail.and.Qiscover tM a�
<br /> Q -q _ _:. _ -_ _ RA, Merchant:R to v '
<br /> _ ((_. e e al:Analyst.r:one°whoworks,alie retnevalsME, - ti=�
<br /> ® Same as above (check here if the MCA/MRA Contact is the same as the IQA/MRQA contact)
<br /> Location. ❑ Merchant ❑ Submitter ❑ Fulfillment (check one) If Submitter/Fulfillment, Name.
<br /> [:] Mr ❑ Mrs. Elms. First Name. Last Name-
<br /> Title. Phone#, Ext:
<br /> Fax#: Alternate Fax#-
<br /> Email Address.
<br /> Address
<br /> City- State/Prov: Zip/Postal Code- Country-
<br /> Will this contact require access to Transaction History ❑ Report Center ❑ both ❑ ?
<br /> Account Masking for this contact? ❑ Yes ❑ No
<br /> Does this contact have a Paymentech Online User ID? ❑Yes ❑No If yes, provide User ID
<br /> Rev11/18/10 3 151
<br /> NewDivisionSetup/cboo
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