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CHASE CO <br />Paymentech <br />Merchant Services * 4 Northeastern Boulevard, Salem, NH 03079-1952 * www.chasepaymentech.com • <br />Phone: (603) 896-6000 e Fax: (603) 896-8715 * Merchant—Services@ChasePaymentech.com <br />'�:,PRGCESSINd <br />SECTION METH60'(c666bbdJ' <br />El 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 F] Terminal Capture F-1 <br />Connectivity: Dial El NetConnect R (If NetConnect see requirements below) <br />If NetConnect: Where is your software hosted/configured? Corporate locationR or Division locationR <br />NetConnect Contact Name: Email address: <br />Userld if existing: Phone: <br />PIN Pad Type and quantity?(forPIN BASE DEBIT Only) Quantity: <br />Is PIN Pad Existing R or PIN Pad Purchase NeededR <br />Injection — Will you be using the Chase Paymentech Encryption Key [I or you do own your own Encryption Key? 1771 <br />Who will be injecting the Encryption Key into your PIN Pad? Please select one below: <br />FI Chase Paymentech Solutions F] Other Vendor Name: <br />Equipment/Terminals: <br />Will you [I Purchase? El Rent? (US Only) <br />❑ Use existing equipment? M Yes E] No <br />Terminal/Equipment Type: <br />If purchase or rent, date needed by: <br />Terminal quantity? <br />Printer Type: <br />Host Capture [I Terminal Capture F-1 <br />Connectivity: Dial E] NetConnect M Wireless M <br />NetConnect Contact Name: <br />Userld if existing: <br />PIN Pad Type and quantity? (for PIN BASE DEBIT Only) <br />(If NetConnect see requirement below) <br />Email address: <br />Phone: <br />Printer quantity? <br />Quantity: <br />Is PIN Pad Existing n or PIN Pad Purchase Needed n <br />Injection — Will you be using the Chase Paymentech Encryption Key [I or you do own your own Encryption Key? El <br />Who will be injecting the Encryption Key into your PIN Pad? Please select one below: <br />El Chase Paymentech Solutions n Other Vendor Name: <br />Store Phone #: Terminal Line Phone #: <br />Customer Service Phone # (if different then Store Phone #) <br />Dial Out Prefix (9,8,5): <br />Eq u ipmenVKits/I m printers Ship To Address (if different than store Attention to: <br />location) Please ensure a contact will be available to accept shipment: <br />Default will be Store Manager <br />Street Address: <br />City: <br />Ship to contact's phone#: <br />Store Opening Date: <br />State/Prov: <br />Zip/Postal Code: Country: <br />Ship to contact's email: <br />Special Requirements: <br />Do you require a "re -program" kit? (overlay, quick reference guide, etcJ Yes[ --J No[] <br />Do you require an Imprinter? E]Yes FlNo Type of Imprinter required: With Dater E] or Without Dater M <br />Do you require an Imprinter Plate? E]Yes FlNo <br />Do you require a Welcome Kit? (this includes sales drafts, credit drafts, etc) YesE] NoE] <br />7 155 <br />Rev11/18/10 New Division/cboo <br />