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CHASECP ' 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 /> =rte : = <br /> OT <br /> �8 P.RO.0 ETH ;, _ . - _:. •: 4•._�: �- , <br /> EBBING M t, ., <br /> :SEC;TION <br /> �- --- -- -- OD continued - � .. ;.�....•.:. �`:�.�.-_ ;:�:��w.=�;r,�;.�"`t`�;h�..:.'_ _-;>�'-.;: <br /> ❑ 5. Will you be using a Point-of-sale terminal (US & Canada only) or Point-of-Sale software? <br /> Point of Sales Software: <br /> POS/Software Name Host Capture ❑ Terminal Capture ❑ <br /> Connectivity, Dial ❑ NetConnect ❑ (If NetConnect see requirements below) <br /> If NetConnect: Where is your software hosted/configured? Corporate location❑ or Division location❑ <br /> NetConnect Contact Name* Email address <br /> Userld if existing Phone <br /> PIN Pad Type and quantity?(for P/N BASE DEBIT Only) Quantity, <br /> Is PIN Pad Existing ❑ or PIN Pad Purchase Needed❑ <br /> Injection—Will you be using the Chase Paymentech Encryption Key❑ or you do own your own Encryption Key? ❑ <br /> Who will be injecting the Encryption Key into your PIN Pad? Please select one below <br /> ❑ Chase Paymentech Solutions ❑ Other Vendor Name <br /> Equipment/Terminals: <br /> Will you ❑ Purchase? ❑ Rent? (US Only) If purchase or rent, date needed by: <br /> ❑ Use existing equipment? ❑ Yes ❑ No Terminal quantity? Printer quantity? <br /> Terminal/Equipment Type: Printer Type. <br /> Host Capture ❑ Terminal Capture ❑ <br /> Connectivity, Dial ❑ NetConnect ❑ Wireless ❑ (If NetConnect see requirement below) <br /> NetConnect Contact Name Email address. <br /> Userld if existing Phone. <br /> PIN Pad Type and quantity? (for PIN BASE DEBIT Only) Quantity: <br /> Is PIN Pad Existing ❑ or PIN Pad Purchase Needed❑ <br /> Injection-Will you be using the Chase Paymentech Encryption Key ❑ or you do own your own Encryption Key? ❑ <br /> Who will be injecting the Encryption Key into your PIN Pad? Please select one below- <br /> [] Chase Paymentech Solutions ❑ Other Vendor Name, <br /> Store Phone#- Terminal Line Phone #- Dial Out Prefix (9,8,5). <br /> Customer Service Phone# (if different then Store Phone#) <br /> Equipment/Kits/Imprinters Ship To Address (if different than store Attention to <br /> location)Please ensure a contact will be available to accept shipment: <br /> Street Address: Default will be Store Manager <br /> City- State/Prov Zip/Postal Code Country- <br /> Ship to contact's phone#: Ship to contact's email: <br /> Store Opening Date Special Requirements <br /> Do you require a "re-program" kit? (overlay, quick reference guide, etc.) Yes❑ No❑ <br /> Do you require an Imprinter? ❑Yes ❑No Type of Imprinter required: With Dater ❑ or Without Dater❑ <br /> Do you require an Imprinter Plate? ❑Yes ❑No <br /> Do you require a Welcome Kit? (this includes sales drafts, credit drafts, etc) Yes❑ Nor-1 <br /> 155 <br /> Rev11/18/10 New Division/cboo <br />