|
DocuSign Envelope ID: 7BAFA4EF- DE91- 4D64- A904- 630EDDFF2843
<br />SUBSTITUTE FORM W -9
<br />® GOVERNMENT
<br />❑ NON- PROFIT CHARITABLE OR SOCIAL (INCLUDE DOCUMENTS THAT SUPPORT TAX EXEMPT STATUS)
<br />❑ OTHER
<br />♦ LEGAL BUSINESS NAME*: Orange County Government
<br />`NAME OF BUSINESS AS SHOWN ON YOUR BUSINESS INCOME TAX RETURNS. FOR SOLE PROPRIETORS, THIS SHOULD ALWAYS BE THE OWNER'S NAME.
<br />♦ LEGAL BUSINESS ADDRESS (NO PO BOX): ZOO S. Cameron Street
<br />/TIN (EMPLOYER ID #): 556-6000327
<br />• CITY: Hillsborough
<br />♦ STATE: NC
<br />♦ ZIP CODE: 27278
<br />OR
<br />/TIN (SOCIAL SECURITY #):
<br />REPRESENTATIONS AND CERTIFICATIONS
<br />®COMPANY
<br />Company Representations and Certifications. By signing below, the applicant company ( "Company") and its representatives) represent and warrant to Elavon, Inc. ( "Elavon" or "member" as
<br />applicable), with offices at 7300 Chapman Highway, Knoxville, TN 37920 (collectively, "we" or "us ") that (i) all information provided in this company application ( "Company Application ") is true and
<br />complete and properly reflects the business and financial condition of Company; and (ii) the persons signing this Company Application are duly authorized to bind Company to all provisions of this
<br />Company Application and the Agreement. The signature by an authorized representative of Company on the Company Application, or the transmission of a Transaction Receipt or other evidence of a
<br />Transaction to us, shall be the Company's acceptance of and agreement to the terms and conditions contained in the Agreement including, without limitation, this Company Application, the Terms of Service
<br />( "TOS "), the Addendum to the Terms of Service for Government/Institutional Companies attached hereto, and the Operating Guide incorporated herein by this reference and located at our website at
<br />https:// www. merchantconnect .conVCWRWeb /i)df/TOS ENG.pdf and htti)s:// www .merchantconnect.com/CWRWeb /odf /OPERATING GUIDE Eng.pdf, respectively. If you are accepting electronic payments
<br />through Transend Pay you also agree to the Terms and Conditions set out under the Resources tab at www.elavon.com/transendpay, and as subsequently amended in the Operating Guide in the Transend
<br />Pay Services Chapter. If Company does not have access to view the TOS or Operating Guide at our website please contact our customer service center. Notwithstanding any such non - receipt of the TOS or
<br />Operating Guide, Company agrees to comply with the Agreement, and all applicable laws, rules, and regulations including the rules and regulations of the Payment Networks, and understands that failure to
<br />comply will result in termination of processing services. Capitalized terms shall, unless otherwise defined in this Company Application, have the same meaning ascribed to them in the TOS and Operating Guide.
<br />Company must obtain an Authorization Code via electronic terminal or similar device before completing any transaction. Company understands that an AUTHORIZATION CODE IS NOT A GUARANTEE OF
<br />ACCEPTANCE OR PAYMENT OF A TRANSACTION. RECEIPT OF AN AUTHORIZATION CODE DOES NOT MEAN THAT COMPANY WILL NOT RECEIVE A CHARGEBACK FOR THAT TRANSACTION.
<br />Company and its representative(s) authorize us prior to our acceptance of this Company Application and from time to time thereafter, to investigate the business history and background of Company and to
<br />obtain credit reports or other background investigation reports on Company that we consider necessary to review the acceptance and continuation of this Company Application. Company also authorizes any
<br />person or credit reporting agency to compile information to answer those credit inquiries and to furnish that information to us.
<br />IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING A NEW ACCOUNT. To help the government fight the funding of terrorism and money laundering activities, Federal law requires all
<br />financial institutions to obtain, verify, and record information that identifies each person who opens an account. This means we will ask for certain information and identifying documents to allow us to identify
<br />you.
<br />This Company Application may be signed in one or more counterparts, each of which shall constitute an original and all of which, taken together, shall constitute one and the same Company
<br />Application. Delivery of executed counterparts of this Company Application may be accomplished by a facsimile transmission, and a signed facsimile or copy of this Company Application shall constitute a
<br />signed original.
<br />All companies must comply with the requirements of the Payment Card Industry Data Security Standards ( "PCI DSS "). Elavon requires Level 4 companies (determined based on Transaction volume) to validate
<br />PCI DSS compliance on an annual basis, with initial validation to occur no later than ninety (90) days after account approval. Any company that has not validated PCI DSS compliance within ninety (90) days of
<br />account approval, or in subsequent years on or before the anniversary date of account approval, will be charged a monthly non - compliance fee of $59.99 until Elavon is provided with validation of PCI DSS
<br />compliance. Company may be eligible for Data Breach Financial Assistance Coverage following account approval and PCI DSS compliance validation. See the PCI Compliance Program Overview for
<br />assistance details and conditions.
<br />American Express Acceptance Program (Acceptance Program). If Company has elected to accept American Express® Transactions (as indicated in the Card Acceptance section of this Company Application),
<br />in addition to all other terms of this Agreement, Company agrees to the Acceptance Program terms of the TOS. By signing below or by accepting a Transaction initiated with an American Express® Payment
<br />Device, Company expressly authorizes Elavon to submit American Express® Transactions to, and to receive settlement funds from, American Express on Company's behalf. Company further authorizes Elavon
<br />to provide Company's contact information to American Express, and Company agrees that American Express may use and share such contact information for its business purposes and as permitted by
<br />applicable Laws, including to communicate with Company regarding products, services, and resources available to Company's business. American Express's use of the email address and mobile phone number
<br />provided above is subject to the consent to such use as indicated in Section 1 of this Company Application. Consent to American Express's use of contact information for such communications may be
<br />withdrawn at any time by contacting our customer service center. Even if consent is withdrawn, Company may still receive messages related to important information about Company's account from American
<br />Express. Company or Elavon may terminate Company's acceptance of American Express® Payment Devices at any time, with or without cause, without affecting Company's rights and obligations pursuant to
<br />the remainder of this Agreement. Company acknowledges that, if at any time Company is no longer qualified to participate in the Acceptance Program, Company may be enrolled in the standard American
<br />Express® card acceptance program, which may have different terms and conditions than the Acceptance Program, and Company's acceptance of American Express® Payment Devices pursuant to this
<br />Agreement will be terminated. Company acknowledges that American Express is an intended third -party beneficiary of this Agreement, solely with respect to the terms and conditions applicable to Company's
<br />acceptance of Am Devices, and that American Express has the right to enforce such terms and conditions directly against Company.
<br />♦ SIGNATURE: X
<br />dl/:'I/LIL N ,
<br />♦ PRINTED NAME: Bonnie Hammersley
<br />♦ TITLE: County Manager
<br />♦ DATE:6/15/2018
<br />5
<br />SIGNATURE: X
<br />PRINTED NAME:
<br />TITLE:
<br />DATE:
<br />• •
<br />To the best of my knowledge, I certify that the information provided in this Company Application was provided by the Company and is true, complete and accurate. I further certify that the signatures were
<br />provided by the Company's authorized representative.
<br />♦ PRINTED NAME: ♦ REP ID #:
<br />♦ DATE:
<br />♦ REP PHONE #: ♦ REP EMAIL:
<br />USA -GOV -ELV -0218
<br />USA -GOV -ELV -0218
<br />
|