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CHASE CP Merchant Services o 4 Northeastern Boulevard, Salem, NH 03079-1952 o www.chasepaymentech.com • <br />Paymentech Phone: (603) 896-6000 o Fax: (603) 896-8715 * Merchant—Services@ChasePaymentech,com <br />Addendum for Application for Credit Card Processing Service <br />Agreement/New Division Request <br />Date: 7/5/16 Company ID#: <br />Proiected Live Date: 10/5/16 <br />�SIECTIONI: COM PANY/CONTACT'IN FORMATION <br />Company Legal Name: Invoice Cloud, Inc <br />Company Taxpayer ID#: 263972596 <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 0 wholly-owned <br />n partially owned Z affiliate n registered DBA or F1 Other (explain: of the merchant noted above. <br />On behalf of Invoice Cloud Inc <br />(Company Legal Name) <br />11 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� . •I ..' ' ._�4 , I �. I ` <br />- ' <br />Z§#5TI0k.Y;'_d7U�N_E§ S_' `!U N I T�, ffdiff& f'ro' m division, name): <br />i* � . �: 11 ` I . . I . - -­ Ir . - , , <br />4 Y <br />- , ­! <br />Parent Business Unit <br />(up to 30 bytes) <br />Parent Bus.Unit # <br />Name (if applicable): <br />(if applicable): <br />Business Unit Name: County of Indian River BCC <br />(up to 30 bytes) <br />Business Unit #: <br />SECTION'.3:,FUN I NGff new, banking, seb section <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? E) Yes or E]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)?E3 Yes or FINo lino, a new FT/ will be created. <br />If yes, provide FTI # (Section 9 does not need to be completed) <br />Rev1 1/18/10 1 NewDivisionSetup/cboo 149 <br />