La Alabanza

MERCHANT APPLICATION AND AGREEMENT
Agent Office (Print) FLAGSHIP/TOP MOTO Sales Representative (Print) GEOFFREY T KAESTNER Agent Telephone (866) 416-0244 Promo Code Lead No. Program Code

5084

MERCHANT INFORMATION
Legal Name of Business DBA (Doing Business As) (only 22 characters including spaces)

IGLESIA LA FAMILIA, INC.
Street Address (Physical address—No P.O. Boxes)

IGLESIA LAFAMILIA
City State ZIP

1706 Merchantville Ave
Mailing Address (If different from Street Address)

Pennsauken
City

NJ
State

08110
ZIP

1706 Merchantville Ave
Business Telephone Business Fax Telephone

Pennsauken
Merchant Customer Service Telephone

NJ
Tax ID No. (Required—9 digits)

08110
Age of Business

8563170095
Merchant E-Mail

8563170095

8563170095
MerchantCustomer Service E-Mail

223589430

Yrs. 10

Mos. 0

IVANJCASTRO@GMAIL.COM
ISP/CSP E-Mail

IVANJCASTRO@GMAIL.COM
Merchant URL

IVANJCASTRO@GMAIL.COM
List Type of Business/Products/Services Sold and How (Be specific)

WWW.VIRTUALTERMINALONLY.COM
Authorized Business Rep

8661-t-RELIGIOUS ORGANIZATIONS=CHURCH

ISABEL SALVA
OWNERSHIP

51% ownership for a corporation, 100%ownership for a partnership or proprietorship, must be accounted for on the application Sole Proprietorship Partnership Principal’s Name Private Corp. Limited Liability Co. Public Corp. Nonprofit Corp. Ownership % Government (Federal/state/local) Associations/Estates and Trusts Title Medical or Legal Corporation Tax-Exempt Org. (501C) Home Telephone International Organization

IVAN CASTRO
Date ofBirth (mm/dd/yy) (Required)

100
Social Security No. (Required)

TREASURER

6095022444

Driver’s License No. and State/State Issued ID (Required)

Expiration Date (Required)

11/14/1968
1602 RAVENSWOOD WY
Second Principal’s Name Date of Birth (mm/dd/yy) (Required)

137948760

137948760 NJ
City

11/14/2012
State ZIP

Street Address (Physical address—No P.O. Boxes)

CHERRYHILL
Ownership % Social Security No. (Required) Title Home Telephone

NJ

08003

Driver’s License No. and State/State Issued ID (Required)

Expiration Date (Required)

Street Address (Physical address—No P.O. Boxes)

City

State

ZIP

SETTLEMENT ACCOUNT (you MUST attach a voided check)
We will automatically debit your Settlement Account for any amounts owed to us under theMerchant Agreement. Bank Name Transit Routing No. Account No. Telephone Bank Contact

Commerce Bank, National Association

031201360

4639456

8567958999

MASTERCARD®/VISA® /DISCOVER® NETWORK MARKETING METHOD
Combined Estimated Monthly Volume Typical Ticket/Sales Amount Estimated Highest Ticket/Sales Amount Face to Face Mail Order (MO) Telephone Order (TO) Internet Total Swiped Keyed WithImprint Keyed Without Imprint Total $ 10000 $ 500 $ 1500 NEW EQUIPMENT Terminal Printer % % % % 100% PIN Pad Other Software Product Turnkey/VAR Other % % % 100% TeleCharge IVR*
Virtual LP-FD Gbl Gtwy

EQUIPMENT/SOFTWARE
REPROGRAM No. Units No. Units No. Units No. Units CARDnet Platform Nashville Platform Auto-Close Retail Restaurant Tips? Tips? Omaha Platform Buypass Platform Yes Yes or Yes orNo No No

0
0

100
0

Debit (Check the functions for which a surcharge will be applied and list amount.) Purchase Surcharge Cash-Back Surcharge Cash-Back Limit $ $ $

0
0
100

Purchasing Card/Level II

*Notwithstanding anything to the contrary in the Merchant Agreement, the term for a TeleCharge Merchant account is month to month.

PROCESSOR
Are you now processing or have youever processed MasterCard/Visa/Discover® Network? Name of Processor Yes No (If yes, attach a previous processor’s statement.) Yes No (If yes, attach explanation.)

Have you ever had a card processing relationship terminated? Yes No

Do you use any third party to store, process or transmit cardholder data? If yes, give name and address:

SITE INSPECTION
Person/authorized company performing...