NEW OFFICE / PROVIDER INTAKE FORM

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PLEASE COMPLETE THE FORMS BELOW AND YOUR LQPAY SALES EXECUTIVE WILL SEND THE AGREEMENT VIA DOCUSIGN

If you are signing up for separate corporate accounts with LQpay, please complete one of these forms for each corporate entity/EIN separately and email to the address below.*

*Individual EINs/offices that are not linked together under a single LQpay account/portal require a separate form.

OWNERSHIP / CORPORATE ACCOUNT HOLDER INFORMATION

Corporate Name of Account / Business: (as listed on bank account)

Company’s EIN Number(s)

Corporate Address of Account: (main office location)

Authorized Signor / Print First and Last Name:

Authorized Signor Email Address

Authorized Signor Phone Number

How many office locations do you have?

PARTNER MSP CONTACT INFORMATION

Name

Email Address

Phone Number

LQpay Merchant Paperwork Request Form

Don't lose your work! Your progress will be saved automatically as long as this browser tab remains open. If you close or refresh the tab, your entered information will be lost.

PLEASE COMPLETE THE FORMS BELOW AND YOUR LQPAY SALES EXECUTIVE WILL SEND THE AGREEMENT VIA DOCUSIGN

If you are signing up for separate corporate accounts with LQpay, please complete one of these forms for each corporate entity/EIN separately and email to the address below.*

*Individual EINs/offices that are not linked together under a single LQpay account/portal require a separate form.

Company Name (As it appears on Bank Account):*

I, as a duly authorized signer on the financial institution account identified below, authorize LQ Pay, LLC, (hereafter referred to as “Company”) to perform scheduled or periodic electronic funds transfer debits and/or credits from my account identified below for payments due, or when applicable, apply electronic funds transfer credits to the same. I understand that the authorization may be rejected or discontinued at any time. If any of the below information changes, I will promptly complete a new authorization agreement. Furthermore, if any such electronic debit(s) should be returned or rejected by my financial institution, I authorize, the Company to collect any applicable banking fees by electronic debit from my account identified below.

BANK ACCOUNT SOFTWARE FEES- OFFICE {{n}}

Enter the bank account you want to use for your LQpay software fees. Please Note: Software fees are billed separately from your standard merchant processing fees.

Type of account (please check one)

Checking (voided check only, deposit slips are not accepted)

Savings (deposit slip only)

Name of Financial Institution (bank name)

City

State

Zip Code

Phone Number

Enter the following information located at the bottom of your check or savings deposit slip. (Do not include the check number.)

ABA Bank Routing Number (must be 9 numbers)*

Account Number (not to exceed 17 numbers)*

PLEASE ATTACH AN IMAGE OF YOUR VOIDED CHECK OR DEPOSIT SLIP

Owner/Provider Signature*

Check this box to confirm and approve this electronic signature.

Date (mm/dd/yy)*

Office/Provider Contact — Email Address*

Office/Provider Contact — Phone Number*

Billing Contact Print First and Last Name (if different from above)

Billing Contact Email Address (if different from above)

Billing Contact Phone Number (if different from above)

Please check all days your office is open and fill-in corresponding office hours for each day.

Monday (Hours)*

Wednesday (Hours)

Friday (Hours)

Tuesday (Hours)

Thursday (Hours)

Saturday (Hours)

Sunday (Hours)

This document and the information contained therein, is the proprietary and confidential information of LQpay, Inc. and the document, and the information contained therein, may not be used, copied, or disclosed without the express prior written consent of LQpay, Inc.

LQpay Merchant Paperwork Request Form

Don't lose your work! Your progress will be saved automatically as long as this browser tab remains open. If you close or refresh the tab, your entered information will be lost.

PLEASE COMPLETE THE FORMS BELOW AND YOUR LQPAY SALES EXECUTIVE WILL SEND THE AGREEMENT VIA DOCUSIGN

If you are signing up for separate corporate accounts with LQpay, please complete one of these forms for each corporate entity/EIN separately and email to the address below.*

*Individual EINs/offices that are not linked together under a single LQpay account/portal require a separate form.

CARD READER DEVICE ORDER OFFICE 1:

PAX A920 PRO

WIRELESS DEVICE - CONNECTS VIA WIFI OR MOBILE NETWORK - TOUCHSCREEN, ALL TAP-TO-PAY AND CHIP-INSERT FEATURES

Price Per Unit: $600.00 + Shipping

Enter Quantity for Purchase:*

Signature*

Signature Date:

Shipping Address Same as Above

Same As Above

Device Shipping Address*

OWNERSHIP / CORPORATE ACCOUNT HOLDER INFORMATION

ADDITIONAL INFORMATION

Please answer all the information below. *Indicates Required information.

CONTACT INFORMATION

File system & templates

Multi-user/Shared PC

PMS/EMR/HMS Details

Installation & Privileges

licensing

Security

NOTES

BANK ACCOUNT SOFTWARE FEES- OFFICE {{n}}