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4 I�i�)''�'!jA���i, <br />r:Vi <br />i+' (1 �,7y -�'., d.iC.. <br />'SA ";id's• <br />,r <br />a,•'y} :i r a s' <br />�, '�+w�+� _ CS' <br />..•"{'. .I,-. t`*a ��.Trr,�.`SI J.�E.?i�i+_asur��-}a_ �� .if? a _ �.•_ � _ _ <br />COMPANY PRESIDENT <br />Bob Solari (Board of County Commissioners) <br />(RESIDENTIAL ADDRESS IS PREFERRED, BUT IF NOT AVAILABLE BUSINESS ADDRESS IS ACCEPTABLE) <br />STREET ADDR'ESSSjS <br />180127th Street <br />CITY I <br />Vero Beach STATE FL ZIP CODE 32960 -� <br />COMPANY CFO: 11 <br />(RESIDENTIALADDRESS IS PREFERRED, BUT IF NOT AVAILABLE BUSINESS ADDRESS IS ACCEPTABLE) <br />STREET ADDRESS 11 <br />CITY_JE <br />STATE ZIP CODE <br />IS THERE ANYONE NOT LISTED ABOVE WHO HAS THE AUTHORITY TO MAKE FINANCIAL DECISIONS OR CONTROL COMPANY POLICY ON BEHALF OF YOUR BUSINESS? <br />❑ YES OWNER ADDENDUM REQUIRED (SALES REPRESENTATIVE WILL PROVIDE) RNO <br />b i <br />t tr ` '- °r-";'�".r tie(tie •.: ,r}, -.y;_« ., L111 _ e.1'� - ,.'%, I"a.'; K • --- - - . ;I L. <br />'Nit XV <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 15 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) Bab Solari <br />TITLE (please print) <br />Board of County Commissioners <br />TELEPHONE NUMBER 772.226-1440 <br />EMAILADDRESS: <br />bsolari@ircgov.com <br />SIGNATURE <br />DATE: <br />+ #" + • , .¢i; .. A <br />.icy {.'� y ,q� i <br />`yx ^.� 'Y•s, ia�.# K �.. �� ••C., 2"...'.W,.X .i.R. � �_'.Fsx -�...J v �.. �L .?Y _ �}) f � _ <br />1, the undersigned, being an officer/principal of represent and warrant that the statements made on this document are correct and factual. 1PMorgan Chase <br />Bank, NA ("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) Bab Solari <br />TITLE (please print <br />Board of County Commissioners <br />SIGNATURE_ <br />DATE <br />_7 <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 />STREET ADDRESS 180127th Street <br />CITY T <br />VeroBeachSTATE <br />FL ZIP CODE <br />32960 <br />• , ,FR Fyr'...f h- rel:.' '` y_ .-'G�'%,• 5->� "'r r+.aV ix *r, +�, ,.s it <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 />