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F• 'v n ''r;i;;=e_'" �;�t. d^�e'�. ».r4 —. - xa• .:.i•. a-t: — _ ro - .cx <br /> a M 2U az t4_sem ft µ r+ 4� .y <br /> NOR � <br /> A� • ':f"�i:�.=� t.a � ^i'' ., `A- _ 'ke�'a= �`'-�-Y;-}%•:�+ 1. 'Y t �1�1, <br /> N. �.* �`+� 2�` �`„ �-���• r �+�,_ ,� "yam- .. <br /> ' `- <br /> :.�?<tz_�R'c <br /> COMPANY PRESIDENT: Bob Solari(Board of County Commissioners) <br /> (RESIDENTIAL ADDRESS IS PREFERRED,BUT IF NOT AVAILABLE BUSINESS ADDRESS IS ACCEPTABLE) <br /> STREET ADDRESS 1801 27th Street <br /> CITY Vero Beach STATE FL ZIP CODE 32960 <br /> COMPANY CFO: IF <br /> (RESIDENTIAL ADDRESS IS PREFERRED,BUT IF NOT AVAILABLE BUSINESS ADDRESS IS ACCEPTABLE) <br /> STREET ADDRESS <br /> CITY STATE ZIP CODE <br /> FE]OS <br /> THERE ANYONE NOT LISTED ABOVE WHO HAS THE AUTHORITY TO MAKE FINANCIAL DECISIONS OR CONTROL COMPANY POLICY ON BEHALF OF YOUR BUSINESS? <br /> YESOWNER ADDENDUM REQUIRED(SALES REPRESENTATIVE WILL PROVIDE)IS <br /> f�''-,..�f� �S'<. .,. 4` '-'� o a` lk" �: - -'r �r_'``I�, �+ `+- v 7a' a'•s: <br /> ter. o � • • o • o �: o _ o � e �; Y�.� •;�-��a ";:��r��-�„`w= �'�,�, <br /> ' '' - � ---. '.`' -_ `' _ `-T+- =• '�.. .a .s:. •` r..Itdc:�:�..sr.;.. a+�a��,".`s�.-.t:s`_N:6;.�r_w v..t�ba..b?-?�':�'�:.�-L3.z2.aL''•���� �Ck+T�S <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 SET UP 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 DATE: <br /> 1,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) 11 Board of County Commissioners <br /> SIGNATURE -11 DATE IF <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 /> ------------------------------------------------------------------------------------------------- <br /> STREETADDRESS 180127th Street <br /> CITY Vero Beach STATE FL ZIP CODE 32960 <br /> R`�- <br /> jog +S+•toil <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. <br /> Rev 11/15 <br /> Page 2 of 2 Paymentech Contract No.063576 <br /> 160 <br />