2018-205-E Health - Elavon credit card fees

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DocuSign Envelope ID: 7BAFA4EF- DE91- 4D64- A904- 630EDDFF2843 N E W C O M P A N Y A P P L I C A T I O N- G O V E R N M E N T/ I N S T I T U T I O N A L USA- GOV -ELV -0218 COMPANY INFORMATION 0 ♦ DBA NAME: Orange County Government CONTACT NAME: Gary Donaldson ♦ DBA ADDRESS TYPE: Business ♦ DBA ADDRESSI (NO PO BOX): 200 S. Cameron Street DBA ADDRESS 2: ♦ CITY: Hillsborough ♦ STATE NC ♦ ZIP CODE: 27278 ♦ COUNTRY OF PRIMARY BUSINESS OPERATIONS: USA ♦ BUSINESS COUNTRY OF FORMATION: USA ♦ DBA PHONE #: (919)245 -2453 ► DOES COMPANY HAVE THE ABILITY TO ISSUE BEARER SHARES AS OWNERSHIP STAKE IN THE COMPANY? No (REQUIRED IF COUNTRY OF FORMATION IS OUTSIDE OF THE U.S. AND BUSINESS STRUCTURE EQUALS C CORPORATION - CLOSELY HELD, PRIVATE COMPANY, PROF CORP, PUBLIC COMPANY, SUB S CORP, LIMITED LIABILITY COMPANY) DBA FAX #: YEAR ESTABLISHED: MOBILE PHONE #: ♦ LENGTH OF CURRENT OWNERSHIP: YEARS, MONTHS ♦ EMAIL ADDRESS: gdonaldSon@orangecountync.gov CIP EXEMPTION: BENEFICIAL OWNER EXEMPTION: OTHER ADDRESS IFDIFFERENTTHANABOVE ® MAILING ❑ SHIPPING ❑ SEE ALSO SPECIAL INSTRUCTIONS (MORE THAN ONE OPTION MAY BE SELECTED) In - LOCATION NAME: Orange County Health Department PHONE #: (919)245 -2414 CONTACT: Rebecca Crawford FAX #: (919)644 -3007 ADDRESS: 300 W. Tryon Street CITY: Hillsborough STATE: NC ZIP CODE: 27278 STATEMENTS/ RETRIEVALS /CHARGEBACKS STATEMENTS: ❑ DBA OR ® MAILING OR ❑ W -9 AUTO SEND: ® YES ❑ No (CHAIN COMPANIES ONLY- MUST INCLUDE CHAIN SETUP FORM) RETRIEVALS: MAIL TO: ❑ DBA ® MAILING OR FAX TO: ❑ DBA ❑ MAILING OR EMAIL TO: OR ❑ ONLINE CASE MANAGEMENT (OCM) CHARGEBACKS: MAIL TO: ❑ DBA O MAILING AND FAx To: ❑ DBA ❑ MAILING OR EMAIL TO: OR ❑ ONLINE CASE MANAGEMENT (OCM) 0 CONTACT INFORMATION AUTHORIZED REP ♦ ❑ OFFICER ❑ MANAGER ® AUTHORIZED REPRESENTATIVE ❑ OTHER: ♦ FIRST NAME: Rebecca MN: ♦ LAST NAME: Crawford ♦ TITLE: Finance and Admin Services Director ♦ US PERSON: Yes ►CONTACT ADDRESS (No PO BOX): 300 W. Tryon Street ►ADDRESSTYPE: Business ►CITY: Hillsborough ►STATE: NC ►ZIP CODE: 27278 ►DOB: 05 -23 -81 CONTACT PHONE M 9192452414 INDIVIDUAL ID EXEMPTION CLASS: GOVERNMENT ❑ FEDERAL ❑ STATE ❑ LOCAL (POLITICAL SUBDIVISION OF A US STATE) OTHER COMPANY INFORMATION ♦ AVERAGE SALE AMOUNT: $ 171 ♦ CARD PRESENT 98% ♦ CARD NOT PRESENT* 2% ♦ INTERNET* 0% (MUST TOTAL 100 %) ►INTERNET : PRODUCT WEBSITE: l� + +n• / /..n.n.. i.r�nnsni...n +.inn ..i... /i+en.�.+.nen +c /L�e- �I+t�/ ►INTERNET: "CONTACT US" EMAIL: *CUSTOMER SERVICE PHONE # AND PREVIOUS PROCESSOR REQUIRED BELOW ►CUSTOMER SERVICE PHONE #: (919)245-2414 ►PREVIOUS PROCESSOR: First Data ♦ HIGH SALE AMOUNT: $ 861 ♦ NUMBER OF HIGH SALES (ABOVE) ANNUALLY:1 ♦ TOTAL MONTHLY VISA/MC /AMEX/DISC /UNIONPAY SALES: $ 3,000 ♦ ANNUAL REVENUE: $ 39,000 ♦ DESCRIPTION OF PRODUCT /SERVICES OFFERED: Medical Clinic Services SPECIAL PROGRAM MCC ONLY: WHEN DOES THE CUSTOMER RECEIVE THE PRODUCT OR SERVICE? IF NOT SAME DAY, # OF DAYS (INCLUDE SHIPPING TIME FRAME) IF SEASONAL, PLEASE CHECK MONTHS CLOSED BELOW. (CUSTOMER MUST CONTACT CUSTOMER SERVICE TO DEACTIVATE AND REACTIVATE ACCOUNT) ❑ JANUARY ❑ FEBRUARY ❑ MARCH ❑ APRIL ❑ MAY ❑ ,JUNE ❑ JULY ❑ AUGUST ❑ SEPTEMBER ❑ OCTOBER ❑ NOVEMBER ❑ DECEMBER BANK ACCOUNT (CHECKING ACCOUNTS ONLY) ♦ DEPOSIT BANK NAME: Su nTrust ♦ ABA/ROUTING #: 061000104 ♦ DDA ACCOUNT #: 401036167 BILLING /CHARGEBACK BANK NAME (IF DIFFERENT): ABA/ROUTING #: DDA ACCOUNT #: CHARGEBACK BANK NAME (IF DIFFERENT THAN BILLING): ABA/ROUTING #: DDA ACCOUNT #: @@ El FAST FAST TRACK FUNDING MONTHLY FEE USA- GOV -ELV -0218