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CHASE" 0 Merchant Services . 4 Northeastern Boulevard, Salem, NH 03079-1952 • www.chasepaymentech.com • 11sayme tech Phone: (603) 896.6000 • Fax: (603) 896.8715 • Merchant_Services@ChasePaymentech.com ❑ S. Will you be using a Point-of-sale terminal (US & Canada only) or Point -of -Sale software? Point of Sales Software: POS/Software Name: Host Capture ❑ Terminal Capture ❑ Connectivity: Dial[] NetConnect❑ (If NetConnectseerequirementsbelow) If NetConnect: Where is your software hosted/configured? Corporate location❑ or Division location❑ NetConnect Contact Name: Email address: Userld if existing: Phone: PIN Pad Type and quantity?(for PIN BASE DEBIT Only) Quantity: Is PIN Pad Existing ❑ or PIN Pad Purchase Needed❑ Injection — Will you be using the Chase Paymentech Encryption Key ❑ or you do own your own Encryption Key? ❑ Who will be injecting the Encryption Key into your PIN Pad? Please select one below: ❑ Chase Paymentech Solutions ❑ Other Vendor Name: Equipment/Terminals: Will you ❑ Purchase? ❑ Rent? (US Only) If purchase or rent, date needed by: ❑ Use existing equipment? ❑ Yes ❑ No Terminal quantity? Printer quantity? Terminal/Equipment Type: Printer Type: Host Capture ❑ Terminal Capture ❑ Connectivity: Dial ❑ NetConnect ❑ Wireless ❑(IfNetconnectsee requirement below) NetConnect Contact Name: _ Email address: Userld if existing: Phone: PIN Pad Type and quantity? (for P/N BASE DEBIT Only) Quantity: Is PIN Pad Existing ❑ or PIN Pad Purchase Needed❑ Injection — Will you be using the Chase Paymentech Encryption Key ❑ or you do own your own Encryption Key? ❑ Who will be injecting the Encryption Key into your PIN Pad? Please select one below: ❑ Chase Paymentech Solutions ❑ Other Vendor Name: Store Phone #: Terminal Line Phone #: Customer Service Phone # (if different then Store Phone #) Equipment/Kits/Imprinters Ship To Address (if different than store location) Please ensure a contact will be avallabie to accept shipment: Street Address: City: Ship to contact's phone#: _ Store Opening Date: Dial Out Prefix (9,8,5): Attention to: Defaulf will be Store Manager State/Prov: Zip/Postal Code: Country: Ship to contact's email: Special Requirements: Do you require a "re -program" kit? (overlay, quick reference guide, etc.) Yes❑ No❑ Do you require an Imprinter? ❑Yes ❑No Type of Imprinter required: With Dater ❑ or Without Dater ❑ Do you require an Imprinter Plate? ❑Yes ❑No Do you require a Welcome Kit? (this includes sales drafts, credit drafts, etc) Yes❑ No❑ Rev11118/10 7 New Division/cboo