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CHAS E O " Merchant services • 4 Northeastern Boulevard, Salem, NH 03079-1952 . www.chasep2ymentech.com <br />paymentpch Phone: (603) 696-6000 • Fax: (603) 896-8715 . Merchant—SeMces@ChasePaymentech.com <br />Please check below if applicable: <br />® Bill Payment (A Bfll Payment transaction is a transaction loran ongoing service/billing cycle that is known and agreed upon In <br />advance by the merchant and cardholder. i.e. Membership or Insurance, etc.) <br />Do you stock product? ❑ Yes ® No Do you provide custom orders at time of sale? <br />Do you own the product at the time of sale? ® Yes ❑ No <br />Do you drop ship the product? ❑ Yes ® No If yes, what %: <br />Are you filling your own merchandise orders? ® Yes ❑ No <br />If no, who is your fulfillment service bureau? <br />Fulfillment Contact: Phone #: <br />❑ Yes ® No <br />SECTIONS CHARGEBACKCONTACT, (regWred) IQA(Manager/sgpervisor 'o lewho;assignsWork6MCAs). <br />(Required f6r retail and Discover) M RQA.(Ivfagager/supeN�sor- on9 who:asslgns worfc"Io MRAs) `: <br />N0fl7: This contact may redeiv¢'any exception docur *an.6 that may:nded to be mailed orfazed If nbt per[icipahng m;Gharcjehack " . <br />Mara - ementthls Wilbbe the default cortact.for Cha aback Mailfn second contact will not ba re wre <br />Location: ❑ Merchant E Submitter ❑ Fulfillment (check one) If Submitter/Fulfillment, Name: <br />® Mr. ❑ Mrs. ❑ Ms. First Name: John Last Name: Morabito <br />Title: CTO Phone #: 703-825-3525 Ext: <br />Fax #: 877-256-8330 Alternate Fax #: <br />Email Address: Imorabito@invoicecloud.com <br />Address: 1815 Beulah Rd <br />City: Vienna State/Prov: VA Zip/Postal Code: 22182 Country: USA <br />Will this contact require access to: Transaction History ❑ Report Center ❑ both ® ? <br />Account Masking for this contact? ® Yes ❑ NO <br />Does this contact have a Paymentech Online User ID? ❑Yes ®No If yes, provide User ID: <br />Ck1AftGE6{#CK CONTACT (required) MCA (tilerchant ChargebackAnalys( one Whb works the;chargebaEk'sJ <br />Re uiredformbil indplscoyef MRA. MerchantRatrieva/Analyst—one.who.worksths'letrieva7s . <br />® Same as above (check here if the MCA/MRA Contact is the same as the IQA/MRQA contact) <br />Location: ❑ Merchant ❑ Submltter ❑ Fulfillment (check one) If Submitter/Fulfillment, Name: <br />❑ Mr. ❑ Mrs. ❑ Ms. First Name: Last Name: <br />Title: Phone #: Ext: <br />Fax M Alternate Fax M <br />Email Address: <br />Address: <br />City: State/Prov: Zip/Postal Code: Country: <br />Will this contact require access to: Transaction History ❑ Report Center ❑ both ❑ ? <br />Account Masking for this contact? ❑ Yes ❑ No <br />Does this contact have a Paymentech Online User ID? ❑Yes ❑No If yes, provide User ID: <br />Revl 1/18/10 25C-62 NewDivisionSetup/oboo <br />