ACH Authorization | Card Concepts Inc.

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Jira Issue Key

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Reader Type*

This is an ACH Authorization form for services provided by or on behalf of Card Concepts Inc. It is only intended for the account indicated below.

Account Number*

Environment*

Product*

Payment Program*

Owner Name*

First Last

Owner Email*

Owner Phone*

Legal Name of Business*

Doing Business As (DBA) Name*

Business Type*

Years in Business*

Social Security (SSN) or Tax ID (EIN)*

DBA Address*

Street Address Address Line 2 City State Zip Code

Do you own or rent the premises where the DBA is located?*

Name, email, and home address of any partner/principle with greater than 25% ownership*

Do you consent to receive important messaging via phone or SMS text from Card Concepts Inc.?*

Yes - Opt-in

No - Opt-out

By selecting "Yes - Opt-in" on this form, you agree to receive communications via phone and SMS from Card Concepts Inc. and its affiliated entities. These communications may include promotional offers, customer care updates, account notifications, event information, and other relevant content. You can opt-out at any time.

Accepting Credit Cards?*

Accepting EBT?*

Credit Card Gateway*

Card Concepts Inc. only utilizes gateway accounts configured by CCI personnel.

The following fees are charged by the credit card gateway service:

One-Time Setup Fee: $49.00
Monthly Service Fee: $15.00
Per Transaction Fee: $0.06
Daily Batch Fee: $0.06

One-Time Setup Fee: $99.00
Monthly Service Fee: $15.00
Per Transaction Fee: $0.07
Daily Batch Fee: NONE

One-Time Setup Fee: $100.00
Monthly Service Fee: $30.95
Per Transaction Fee: $0.06
Daily Batch Fee: NONE

Fees are already included in the merchant service provider (Paystri) contract.

CCI Hosting Fees

Base Hosting Fee

Number of Satellites*

Additional Satellite Fee per Month

Number of Card Readers*

Additional Card Reader Fee per Month

Number of CMRs*

CMR Plan*

CMR Plan Fee per Month*

Hosting Total*

Account Type*

Name on Account*

ABA Routing Number*

9-digits

Bank Account Number*

Bank Name*

Bank Address*

Street Address Address Line 2 City State Zip Code

I hereby authorize Card Concepts Inc. (hereafter "CCI") and the credit card gateway service to initiate debit entries for the sums detailed above and initiate (if necessary) credit entries and adjustments for any debit entries in error to the account indicated in bank information named above, to debit and/or credit the same to such account.

This authority is to remain in full force and effect until CCI has received written notification from customer of said authority's termination and in such manner as to afford CCI a reasonable opportunity to act.

To agree to all terms above and contained herein, please enter your full name below and sign with your mouse/finger.

Please type out your full name.*

Signature*

ACH Authorization Form

CCI Hosting Fees