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MERCHANT APPLICATION Discover/Visa/MasterCard Sales Profile U Corporation (Privately Traded) ❑Corporation (Publicly Traded) Medical or Legal Corp❑Retail Merchant # (Be Accurate): ❑ New Location ❑ Additional Location a 2900 Bristol Street • F-206 • Costa Mesa, CA 92626 - 866.346.4011 Card Swipe http://www.cardflexprepaid.com Merchant Accepts DonateWise Now®❑yes❑No By checking Yea and signing this application and agreement, you Indicate your acceplenoe of the Greenwlse GaimSulte and DanateWseNow Program tenns and conditions. r Legal Name (as it appears on your income tax return): Name of Account (Doing Business As): City of Santa Ana Citv of Santa Ana Legal Address: Physical Street Address (No P.O. Box): 20 Civic Center Plaza 20 Civic Center Plaza City: State: Zip: City: State: Zip: Santa Ana CA 92701 Santa Ana CA 92701 Phone #: Contact: DBA Phone #: Fax #: ( 714 ) 647-5400 Christine Duarte ( 714 )647 5400 r \n ust Choose One Mailing Address I E -Mail Address: Website Address: O DBAAddress ❑Legal Address cduane@sante-ana.org www.http://www.ci.santa-ana.ca.us/ Federal Tax # aincome iex ia� j°f # of Locations Years in Business Years Owned Business 9 15 16 10 10 10 17 IS 15 1 1 143 143 Place of Legal Formation: Country of Primary Business Operations: CA USA Bank Reference: Contact: Phone #: Robert Donahue JPMor an Chase 949 471-9869 Christine C. Duarte 714 )647-5335 Name: Title: DateofBirth, Applicant's SS #: % Equity Ownership: 1. Residence Address: City: State: Zip: #Years: US Government Issued ID#: Type of ID: Expiration Date: Country of Citizenship (if not UBI: Home Phone: Name: Title: Date of Birth: Applicant's SS #: % Equity Ownership: 2. Residence Address: City: State: Zip: # Years: US Government Issued ID#: Type of ID: Expiration Date: Country of Citizenship (if not US): Home Phone: Type of Ownership: L13ole Proprietor Assoc/Estates/irusts Joint Venture --®Government Merchant Type: Discover/Visa/MasterCard Sales Profile U Corporation (Privately Traded) ❑Corporation (Publicly Traded) Medical or Legal Corp❑Retail (Be Accurate): ❑ ❑Tax Exempt Ongdel ❑Single Member LLC ❑Multi Member LLC ❑Civic Assoc ❑ Restaurant Card Swipe 0 % nL'm'led Partnership ❑Porfcal Ong ❑Other: Limit d Par ❑Lodging Manual Key Entry with Imprint, CaN Present 0 Type of Goods or Services Sold: SIC Code: yp Business License ❑ SBNICe 0Internet Mail Order/telephone 0 % Do you rrently accept Discover®MswMaslercard? : Name of Current Processor: cu ®Yes ❑No Palea u, vee ro° soouw submit a oum,nn months to roamsyp .) ❑Home Based ❑ Other nterrut Total = 100% 100% Has Merchant or any associated principal disclosed below filed ❑Yes Date: bankruolcv or been subject to involuntary bankruptcy? JNo E2 G2 1822ARoute66GlendoraCA91740 Craig Sunada ( 909 ) 680-841 Name: Address: Contact: Phone #; Merchant Location: �Retaii Location with Store Front Ld Office Building ❑ Internet IJ Residence U Other Area Zoned: LJ Commercial I❑Industrial L) Residential Square Footage: ❑0-250 ❑251-500 LJ 501-2,000 02,001+ Does the amount of inventory and merchandise on shelves and floor appear consistent with this type of business? LA Yes Ll No If No, explain: The Merchant' ® Owns ❑ Leases the Business Premises Landlord Name & Phone #: Further Comments by Inspector (Must Complete) Business appears as represented I hereby verify that this application has been fully completed by merchant applicant and that I have physically inspected the business premises of the merchant at this address and the information stated above is true and correct to the best of my knowledge and belief. Verified and Inspected by: Office #: Representative #: Rep_fe,se tiiv®_, natur ;<✓ Date: Baillie White Copy - Bank • Pink Copy - Merchant Rev2.10/01/2011 CardFlex Financial Services is a registered ISOIMSP of BMO Harris Bank, / .{',,'},Criicago, IL, page 1 of 7