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Bankcard Merchant # 180 Name Iso# ‘agent Narre
MuriiciPAy 9628
Buslness LEGAL Name . , Tax ID # (required, 9 digits)
TOWN OF AURORA 16-6002169
8uslness DBA Name (if different from legal name) Company Website URL
TOWN OF AURORA TAX _; HTTPsAVWW. TOWNOFAURORA, COM
Buslness DBA Phystcal Address . ~ Business Malling Address) *
575 Oakwood Avenue - . 575 Oakwood Avenue
DBA Clty, State arid Zip Code _ > _ Malling City, State and Zip Code .
East Aurora, NY 14052 ; ......| East Aurora, NY 14052" . =
Business Phone Business Fax ae
(716) 652-3280 .
Contact Person ; : Title 5” "| eanalt
Charles Snyder oe = . . ’ | Town Supervisor ” canyder@townotaurota ‘com
Alternate Contact Persor! 7 . Title’ - ence Emiail* :
Jeanne Viger. te, ; Town Clerk.- _ WMiger@townofaurorany. gov
‘T¥pe-of Ownership: -- [2] Sole pibpretoran - 7] Partnership’ Ci cotporation ° = Ep Linitted Llabiity Company = LA Non-Profit Ee, ee
Total Time In Business : Time In Business at This Location . Y Bees
“Years. _ oo Months. Q Years “PT Moiiths ea
: ; ~ CONTROLLING MBNECER (ifdifferent):
Name ae “Title Name aa Title= races
Charles Snydér Town Supervisor .
Residential Address * Residential Address
City, State & Zip Code” nd Social Security Number (SSN) City, State & Zip Code Social Security Number (SSN)
Phone . . %Equity| Oate of Birth Phone % Equity) Date of Birth
Ownership! - {MM/DD/VYYY} . . Ownership (MM/DD/YYYY)
(For any other Individuals with 25% or more ownership, please complete Additional Beneficial Owner Form. a
Average Check/ACH Amount: Average Number of Checks/ACH Monthly:~
$5,000.00. LO : 50
Maximum Check/ACH Amount Requested: Estimated Monthly Check/ACH Volume:
$ 40,000.00 _ $ 50,000.00
: a = PRODUCT INFORMATION. °
1. Describe the product(s) or service(s} being sold: Tax Payments
2. Describe how check/ACH services are to be used (if different than above): NA.
3, How are products delivered? Municipal payment
4;Describe merchant's return/ refund pollcy:No refunds
5. Describe advertising/ sales / marketing protedures:NA
(J Inbound customer calls © [J Outbound customer calls [[] Print Advertisements [1] Point
of Sale {Face-to-Face} (1 other:
(1 Internet Advertisements [] Website “TO Direct Mail Ow
ACTION DESCRIPTOR
Company Name (as it should appear on consumer Sank Statement) Company Phone {as it should appear on consumer Bank Statement) *
Town of Aurora Tax (716) 652-3280
oe FQUIRED INFORMATION.
(&] completed Applicatton Bl Volded Check or Bank Letter
(21 Bank Statement (one month) (212 Months Bank or Processing Statements Applies to Swttsettle only
TD One of the Following: iicurrent Processing Statement [i Business ticense (£3 Utility BE (in business name unless Sole Proprietorship) (= Sales Tax License
[2 customer Authorization Form / Script (required for ACH Debit and Checks-By-Phone)
73 Eglin Pkwy NE, Suite 301, Fort Walton Beach, FL 32548
Application for Merchant Account ~ Check and ACH Processing REVO5152023 Page 1 of £1.
PLEASE NOTE: The complete Merchant Agreement Includes this Application and the Terms and Conditions on elght (8) additional pages.