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CHASE Cp <br />Paymentech <br />Merchant Services * 4 Northeastern Boulevard, Salem, NH 03079-1952 9 www.chasepaymentech.com • <br />Phone: (603) 896-6000 * Fax: (603) 896-8715 e Merchant—Services(cDChasePaymentech.com <br />!.SECTIOWIOREPORT. CENTER AND TRANSACTION HISTORY ACCESS FORM, - <br />1. Please be sure to include the information below for additional contact that requires access to Transaction <br />History and/or Paymentech Online Report Center. <br />2. Report delivery will be web based via Paymentech Online. <br />3. Please note: You, the merchant, are responsible for advising Chase Paymentech of changes in Paymentech <br />Online contacts. Chase Paymentech assumes no responsibility or liability of any kind for Merchant's failure to <br />advise Chase Paymentech of changes to or elimination of Paymentech Online Users. <br />Please be sure to complete all fields below. <br />Salutation: Check one: Z Mr. ❑ Ms. r-1 Mrs. <br />Name: Robert Lapides Title: President, GUB Division <br />Phone #: 781-848-3733 Fax #: 877-256-8330 <br />Address: 30 Braintree Hill Office Park, Suite 303 <br />City: Braintree State/Prov: MA Zip/Postal Code: 02184 Country: USA <br />Email Address: (40 bytes) blapides@invoicecloud.com - <br />(usemame@domain,com) <br />Does this contact have a Paymentech Online User ID? n Yes Z No If yes, please provide User ID: <br />Does this User require access to: ❑ Reporting R Transaction History Z Both Account Masking Z Yes ❑ No <br />For existing merchants — Is this User replacing an individual with Paymentech Online Access? F1 Yes D No <br />If yes, who? Has this individual left the company? M Yes R No <br />For existing merchants — Is this User's access to be mirrored like another User Paymentech Online Access? <br />E3 Yes R No <br />If yes, who? <br />Salutation: Check one: 0 Mr. Ems. R Mrs. <br />Name: Deborah Bowler Title: VP of Operations <br />Phone #: 781-848-3733 Fax #: 877-256-8330 <br />Address: 30 Braintree Hill Office Park, Suite 303 <br />City: Braintree State/Prov: - MA Zip/Postal Code: 02184 Country: USA <br />Email Address: (40 bytes) dbowler@invoicecloud.com <br />(usememe@domain.com) <br />Does this contact have a Paymentech Online User ID? F-1 Yes El No If yes, please provide User ID: <br />Does this User require access to: n Reporting M Transaction History Z Both Account Masking Z Yes M No <br />For existing merchants — Is this User replacing an individual with Paymentech Online Access? R Yes ❑ No <br />If yes, who? Has this individual left the company? R Yes ❑ No <br />For existing merchants — Is this User's access to be mirrored like another User Paymentech Online Access? <br />0 Yes []No <br />If yes, who? <br />For 'additi6haI-Uie'M,,_p'1.6ate'sub it additio-n-aIforms. <br />1, Robert Lapides President, Government, Utilities verify that the <br />and Business Services Division <br />(Print Name) (Title)* <br />contact information is accurate, that I have the authority to make such a request and thus it should be used to grant <br />access for these contacts to access Transaction History and/or the Report Center. <br />Signature: <br />*(must be signed by Executive or Financial Contact) <br />10 <br />Rev1 1/18/10 New Division/cboo <br />158 <br />