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Dual Pricing Program Agreement
Dual Pricing Program Agreement
The undersigned merchant ("Merchant") has elected to participate in the dual pricing program ("Program") administered by J P & D FINANCIAL, INC. ("JP&D"). By signing this Dual Pricing Program Agreement ("Agreement"), Merchant acknowledges and agrees to the following:
1.
Pass Code
Merchant Legal Name
DBA Name
Location
Company Structure
Corporation
LLC
Partnership
Sole Proprietorship
Federal Tax ID
SSN
Phone Number
Fax Number
Contact Name
Home Address
E-mail
Cell Phone
Location has existing ATM
Yes
No
If YES, Surcharge
Note
Print Name
Date
Sign.
Re-Sign
submmit
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