Merchants Group Inc.

Business Information

Merchant's DBA
Name/Outlet Name:

Merchant's Legal Name:

Physical Street Address (No P.O.Box):

Legal Address:

City,State.Zip:

DBA Phone:

Corp. Phone:

Fax:

Contact Name at this Address:

Federal Tax ID#:

Name :

Title :

Date of Birth:

Social Security# :

Home Phone#:

Email

Home Address:

City:

State:

ZIpCode:

Own / Rent?

Former Address:

City:

State:

ZipCode:

Own / Rent?

More Owner/Officers Information

Bank Information (Attach Voided Check or Bank Letter):

Routing No:

DDA/Checking Accounts

Bank 1:

Bank 2:

American Express

By Signing below, I/we represent that the information I/we have provided on the application is complete and accurate and I/we authorize American Express Travel Related Services Company. Inc.("American Express") to verify the information on the application and to receive and exchange information about me. including requesting reports from consumer reporting agencies. If I/we ask American Express whether or not a consumer report was requested .American Express will tell me. and if American Express received a report .American Express will give me the name and address of the agency that furnished it. I/we understand that upon American Express approval of the business entity indicated above to accept the American Express Card the Terms & Conditions for American Express @ Card Acceptance ("Terms & Conditions") will be sent to such business entity along with a welcome letter. By accepting the American Express card for the purchase of goods and/or services .I/we agree to be bound by the Terms & Conditions.

Merchant's Name:

Title:

Date:

Acceptance of Merchant Application and Terms & Conditions / Merchant Authorization

Your Card Services Agreement is between Global Payment Direct, Inc ("Global Direct"}.the Merchant named above, the member named below ("Member") and if applicable the debit Sponsor name below. Member is a member of visa, USA. Inc ("Visa") and MasterCard International. Inc ("Mater Card") Global Direct is a registered independent sales organization of visa and member service provider of MasterCard

A copy of the card services Terms & Conditions, revision number has been provided to you. Please sign below to signify that you have received a copy of a card Services Terms & Condition and that you agree to all terms & condition contained there in. if the merchant application is accepted for the card services merchant agrees to comply with the merchant application and the card services Terms & Condition as may be modified or amended in the future. If you disagreed with any Card Services Terms & Conditions, do not accept services.

IF MERCHANT SUBMITS A TRANSACTION TO GLOBAL DIRECT HEREUNDER, MERCHANT WILL BE DEEMED TO HAVE ACCEPTED THE CARD SERVICES TERMS & CONDITIONS

By your signature below on behalf of merchant, you certify that all information provided in this merchant application is true and accurate and you authorize Global Direct and Global Direct on Member's behalf, to initiate debit entries to merchant checking account(s) in accordance with the card services Terms & Conditions. In addition by your signature below on behalf of Merchant you authorize Global Direct and/or Merchants Group Inc to order a consumer credit report on Merchant and you.

Merchant's Name:

Title:

Date

Global Payment Direct,Inc Name:

Title:

Date

Member Name:

Name of Member(Printed)HSBC Bank USA,NA

Date

Debit Sponsor Name:

Name of Debit Sponsor Concord EFS National Bank:

Date

Personal Guaranty

I/we hereby guarantee to Global Direct, Member and to Debit Sponsor, their successors and assigns the full prompt and complete performance of Merchant and all of Merchant's obligation under the card services Agreement, including but not limited to all monetary obligation arising out of merchant's performance to non-perfomance under the card services Agreement. Whether arising before or after termination of the card services agreement. This guaranty shall not be discharge or otherwise affected by any waiver. Indulgence compromise, settlement extension or credit, or variation of terms of the card services Agreement made by or agreed to by Global Direct, Member, Debit Sponsor and/or Merchant. I/we hereby waive any notice of acceptance of this guaranty. notice of nonpayment or nonperformance of any provision of the card services Agreement by Merchant .and all other notice or demand regarding the card services Agreement. I/we agree to promptly provide to Global Direct .Member, and/or Debit Sponsors any information requested by any of them from time to time concerning my/our financial condition (s).business history, business relationship, and employment information. I/We have read, understand and agree to be bound by the card Services Terms & Conditions provided to Merchant and those terms and conditions contained in this Merchant Application.

Name of Guarantor:

Name of Witness

By checking this box I accepted all the terms & condition mentioned in this application.