HomeMy Public PortalAboutOpenedge formMERCHANT WORKSHEET FOR TYLER TECHNOLOGIES
Return by Fax 410-753-1333 or email to susan.gresham enedgepav.com
BUSINESS INFORMATION
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Legal Address
Merchant "ing Business
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PhyslcalLocatjon Address (NO PO Box t)
CityCityztp zip
Years in Business
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Contact EmailAddress
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Type of Eusrness
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No. of Physical Locatjons
Contact Name
Customer Service Phone
Tax lD No. (9 Digits
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CLrstomer Service Email
Which emailaddress should be usedto receive
(such as account enrollment andlor PCI setup)?
m OpenEdge Which address should receive
monthly statements (Check One)?P
ACCOUNT INFORMATION
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Total Estimated a.nualcredit Card Sale5 Estjmated Average Ticket (Averege credit card sale)
Total Estimated aCH/check Sales (if applicable)
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Bank Routing Number
A voided check or bank verification letter is also required
Bank Account Number (Optronal)
TOTAL SALES PROFILE (Must equal 100%)
Cards Swiped % MailOrder/Phone/lnternet
lf prepaad, how longdoesthe customer
wait before product is received?
'b"Does rnerchant accept transactions
before the customer receives product
or service? i.e. any prepayments
rfyes, for which product or service?
category?
% of cost that is prepayment?
Whata.e you accepting paymentsfor? (indicate allthat apply)' ',(frrLtgS' t i{,u->w,lz"ot
UnLity
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MERCHANT WORKSHEET FOR TYLER TECHNOLOGIES
Return by Fax 410-7S3-1333 or email to susan.gresham@ openedqepav.com
SALES PROFILE (continued)
DBA name
Account (printed
receipt)
DgA address if
different from
maan DBA
different fiom
main DBA
ticket
channel
{ex: Retail,Date ofGo Live
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Cashiering EnerGov-My-Munis Citizen
SelfService
who are your Tyler Representahves?
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Name (First & Last)Tte
What is your planned implementation date?
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Email
Name (First & Iast)Trtle
Please include a voided check or bank verification letter with this workheet
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INFORMATION ABOUTWLER
which TylerTechnology products/applications are you usinS? (check allthat apply)trtrtrtrn tr d tr
DBA phone if
different from
main OBA
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AUTHORIZED SIGNER
Email
clTY OF TYBEE ISI.AXD GEI{ERAL OPENANIJG ACCOUNT 402635
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CITY OF TYBEE ISI.AHD
P.O. BOX27,rg
TYBEE TSLAND, GA 31328
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402635
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DATE
AMOUNT
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