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REPORT TOOLS
<br /> ❑ MCP ONLY OR 0 MCP WITHOCM MONTHLY FEE$ SET UP FEE$ #USERS SET UP TYPE(CHECK ONE) 0 MID 0 CHN ❑ ENT
<br /> ❑ACS MONTHLY FEE$ SET UP FEE$ REMOTE ID
<br /> SUBSTITUTE FORM W-9
<br /> ❑ SOLE PROPRIETOR 0 PUBLIC CORP 0 CLOSELY HELD CORP 0 SUB S CORP 0 GOVERMENT 0 GENERAL PARTNERSHIP
<br /> ❑ LIMITED PARTNERSHIP 0 TAX EXEMPT ORGANIZATION(INCLUDE DOCUhENTS THAT SUPPORT EXEMPT STATUS) 0 OTHER(ASSN/ESTATE/TRUST)
<br /> ❑ LIMTED LIABILITY COI,PANY—TAX CLASSIFICATION(D=DISREGARDED ENTITY,CORPORATION, P=PARTNERSHIP): (IF LLC,PLEASE INDICATE D,C OR P)
<br /> NAME*: City of Everett
<br /> 'NAME(OF BUSINESS)AS SHOWN ON YOUR BUSINESS INCOME TAX RETURNS.FOR SOLE PROPRIETORS, THIS SHOULD ALWAYS BE THE OWNER'S NAME.
<br /> ADDRESS: 333 Smith Island Road OR 11N(EM'LOYER ID#):
<br /> CITY: Everett STATE: WA ZIP: 98201 TIN(SOCIAL SECURITY#):
<br /> COMPANY REPRESENTATIONS AND CERTIFICATIONS
<br /> 5 Company Representations and Certifications. By signing below,the applicant All Companies must comply with the requirements of the Payn>ent Card Industry Data Security Standards
<br /> company ("Compaq)and its representative(s) represent and warrant to Elam, inc. ('PCI DSS'). Eleven requires Leel 4 companies (determined based on Transaction volume) to validate
<br /> , ("Elam' a°Member'as applicable),with offices at7300 Chapman Highway, PCI DSS compliance an an a nnual basis,with initial validation to occur no later than ninety(90)days after
<br /> Knoxville, TN 37920 acccunt approval. My company Meat has not validated PCI DSS compliance within ninety(90)days of
<br /> (collectively, 'we'or'us')that(i)all information provided In this company application("Company account approal, or in subsequent yeas on or before the arriversay date of accent approval, will be
<br /> Application) is true and complete and properly reflects the bsiness,financial motion,and charged a monthly non-compliance fee d$45 until Elam is prodded with velidation of camplialce.
<br /> principal partners,owners,or officers of Company and(ii)the persons signing this Company Company may be eligible fa Data Breech Coverage following accord approval and PCI DSS compliance
<br /> Application are duly authorized to bind Company to all provisions d this Company Application validation See the PCI Canpliance Program Overview for coverage details and cardtiars.
<br /> and the Agreement. The signature by an authorized representative of Company on the Under penalties of perjury{ Company certifies that:
<br /> Company Application, or the transmission of aTrasaction Receipt or other evidence of a 1. The number shown on this Company Application is my correct taxpayer Identification number
<br /> Transaction to us,shall be the Company's acceptance of and agreement to the terms and (or 1 am waiting for a number to be issued to me),and
<br /> conditions contained In the Agreement including,without limitation this Company Application, Z I am not subject to backup withholding because: (a)I am exempt from backup withholding,or(b)
<br /> the Terms of Service("TOS") and the Company Operating Guide("MOG°)ircorpaated herein I have not been notified by the Internal Revenue Service(IRS)that I am subject to backup
<br /> by this reference and located at aur website at withholding as a result of a failure to report all interest or dividends,or(c)the IRS has notified me
<br /> httos:IAwnv.merchantcomect.cam/CWRWeb/pdf/TOS ENG of that 1 am no longer subject to backup withholding,and
<br /> and htos:f/wmimerchahtconnect.conVCWlWeb/De/MOO Ero.pd, respectively. fCompay 3. I ane U.S.citizen or other U.S.person.
<br /> does not have access to view tine TOS or MOG at ar website please contact our customer 4,The FATCA code(s)entered on this form(if any)Indicating I am exempt from FATCA reporting is
<br /> service ceder.Notwithstanding arty such norreceipt of tine TOS or MOG,Company agrees to comma
<br /> comply with the Agreement, and all applicable laws,rules,and regulates including the rules
<br /> and regulators of the Payment Networks, and understand that failure to comply will result in American berms Acceptance Program(Acceptance Program).If Company has elected to accept
<br /> termination ofprocessing services.Capitalized terms shall,unless dhenvise defined in this American Empress®Transactions(asinocated in the Card Acceptance section othis Company
<br /> Company Application, have the same meaning ascribed to them in the TOS and MOG. ication,In addition to all other terms of this
<br /> Appl' ) Agreement, Company agrees to the provisions set forth in
<br /> IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING A NEW ACCOUNT.To Section E(Acceptance Program)of the TOS. By signing below or by accepting a Transaction initiated with
<br /> help the goerrrnad fight the furring of terrorism and money laundering activities,Federal law an American Express®Payment Device, Company eigressly authorizes Elmer to submit American
<br /> requires all financial institutions to obtain,verify, aid record Information that identifies each Fhpress®Transactions to,and to receive settlement funds from,American Express on Camparys behalf.
<br /> person who opens an account This means we will ask for certain information and identifying Company further authorizes Flavor to provide Company's contact information to American E press,and
<br /> documents to allow is to identify you Canpany and its representative(s) authorize as prior to Company agrees that America!Express rimy use and share such contact information for its business
<br /> ar acceptance d this Company Application and from time to time thereafter,to investigate the pLrposes and as permitted by applicable Laws,including to communicate with Canpary regarding
<br /> individurat and business history and background d Company, each such representative and any
<br /> products,services,and resources available to Comparys business.American Empress's use of the email
<br /> other officers,partners,proprietors,and/or owners of Company, and to obtain credit reports or address and mobile phone rumba provided above is subject to the consent to such use as Indicated in
<br /> other background investigation reports on each of them that we consider necessary to reviewSection 1 dthis Company perry Application Consent to America Empress's use of contact information for such
<br /> the acceptance and continuation of this Company Application.Company also autnrizes any communications may be withdrawn at any time by contacting our customer service canter.Even if consent
<br /> parson or credit reporting agency to compile information to answer those credit Inquiries and to is withdrawn, Company may still receive messages related to important information about Comparys
<br /> furnish that information on to us. account from American Express.Company or Elason may laminate Compat/s acceptance of American
<br /> Express®Payment Devices at any time,with or without cause,without affecting Cmparys rights and
<br /> This Company Application may be signed in one or more counterparts, each of which shall obligations pusuad to the remainder of this Agreement Company'acknowledges that, if at any time
<br /> constitute an original]ad all of which,Wan together,shall constitute one and the same Company is no longer qualified to participate in the Acceptance Program,Company may be enrolled in the
<br /> Company Appicatien. Delivery of scouted counterparts of this Company Application may be standard American Express®card acceptance program,which may have cifrerert terms and motions
<br /> accomplished by a facsimile transmission,and a signed facsimile or copy of this Company than the Acceptance Program and Cmpat/s acceptance of American Express®Payment Devices
<br /> Application shall constitute a signed original. pursuant to this Agreement will be terminated Company ackma wledges that American Empress is an
<br /> intended third-party beneficiary of this Agreement,solely with respect to the terms and condtars
<br /> company andel-stands that an authorization code Is not a guarantee of acceptance Or Payment it applicable to Conpays acceptance ofAmerican Express®Payment Devices,and that American Empress
<br /> of a Transaction Receipt of an auterization code does red mean that company will not receive has the right to enforce such toms and con:Hors drectly against Company.
<br /> a Chargeback fa that Transaction
<br /> 'The Internal Rue a does n quire your consent to any provision of this document other than the certifications required to avoid backup withholding _-
<br /> SIGNATURE:eiszt5
<br /> PRINTED NAME: Ray Stephanson TITLE:Mayor > TE21/ 47I/
<br /> SIG rTURF:X PRINTED!JANE:°: TITLE: DAT :: 7'
<br /> PERSONAL GUARANTY
<br /> 6 As a primary inducement to us to accept this Company Application the undersigned Guarantor(s),by signing the Company Application, jointly and severally, ucarditionally and irrevocably,
<br /> guarantee the continuing full and faithful performance and payment by Company of each of its duties and obligations to us(irluding,without limitation,Chargebacis and obligations inconnectim
<br /> with Leased Equipment, if applicable) pursuant to the Company Application and Agreement,as may be amended from time to time,with or without notice.Guarantor(s) understand further that we
<br /> may proceed directly against Guarantor(s)without first adhaustng our remedies against army other person or entity responsible therefore to them or any security held by us a Company. This guarantee will not
<br /> be discharged or affected by the death of the Guarantors, will bind all heirs,administrators, representatives and assigns and may be enforced by or for the bereft of any of err successors. Guarantor(s)
<br /> understand that the inducement to us to accept this Canpauy Application is consideration for the guaranty and that this guaranty remains in full force and effect even if the Guarantor(s)receive no additional
<br /> benefit frail the guaranty. The undersigned hereby directs any consumer reporting agency to furnish a consumer creel report that relates personally to the undersigned upon the request of Eleven or any of its
<br /> designees,successors or assigns and agrees that all parties involved are in compliance with Moe Fair Credit Reporting Act
<br /> SIGNATURE:X None PRINTED NAM: DATE:
<br /> SIGNATURE:X PRINTED NAM: DATE:
<br /> SUBMITTED BY(SALES USE ONLY)
<br /> To the best of my Ivcwledge, I certify that the irdormation provided in this Company Application was provided by the Company and is true,complete and accurate. gather certify that the signatures were
<br /> provided by the Conpahh/s o cars)a officer(s),as appropriate
<br /> SALES REP SIGNATURE:Xn PRINTED NAM=:Kelvin Reid REP ID#: 38096 DATE:
<br /> REP PHONE#:(770)709-7802 REP EMAIL: kreid@bluefhn.com ELAVON USA-MSP-ELV-0416
<br /> TT ST
<br /> A• ROVED TO M
<br /> ..... ,.----N.,.,
<br /> Initials !� �/ , 4 _hI ES,City tOrUSA-MSP-ELV-0716
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