GETTING STARTED WITH MANGOPAZE

An Easy 2-Step Process

Before you know it, you’ll be increasing your sales and upping customer satisfaction like never before. This application will take approximately 40 minutes to complete.

Step 1 - Gather Required Documents

There are a few documents we need you to go find. If you don’t already have them digitized, you’ll need to scan or take a clear picture of each document so you can send them to us later. The documents will need to be in PNG, JPG, JPEG, TIFF, or PDF format.

The required documents depends on the type of business you have

Select the tab that best represents your business type

If a Sole Proprietor:

Statement of Good Standing/Certificate of Good Standing/Certificate of Status from the State

If a Partnership:

Partnership Agreement (must have each owner's % Percentage of ownership)
Statement of Good Standing/Certificate of Good Standing/Certificate of Status from the State

If an LLC:

Articles of Organization
LLC Resolution (If application is not being completed by a controlling interest in the business)
Statement of Good Standing/Certificate of Good Standing/Certificate of Status from the State
Operating Agreement (must have each owner's % Percentage of ownership)
List of Managing Members (Fields provided in the application)

If a Corporation:

Articles of Incorporation
Signed Bylaws (must have each owner's % Percentage of ownership)
Corporate Resolution (If application is not being completed by a controlling interest in the business)
Statement of Good Standing/Certificate of Good Standing/Certificate of Status from the State
List of Officers/Board Members (Fields provided in the application)

If a Non-Profit:

Articles of Incorporation
Signed Bylaws (must have each owner's % Percentage of ownership)
Corporate Resolution (If application is not being completed by a controlling interest in the business)
Statement of Good Standing/Certificate of Good Standing/Certificate of Status from the State
List of Officers/Board Members (Fields provided in the application)

Additional Documentation

Depending on how your business is set up, we may need to get some additional documentation from you. We’ll let you know if we need anything else after reviewing your application, but if you want to get ahead of the game, you can upload any of these now if you think we’ll need it.

State Registration/Fictitious Name Filing (if a DBA or Trade Name are used)
Federal Tax ID Document (formal document displaying the business’ ownership of the EIN)
Owner’s & Information List (Fields provided in the application)
Copy of each beneficial owner’s photo ID (applies to any owner who holds equity of 14.9% or greater
Copy of Cannabis-related licensure required by your state/county/city
Most recent business Federal Tax Return
Voided Check or Bank Letter with Account & Routing Nos.
Balance Sheet, Income Statement, Cash-Flow Statement, as applicable
3 months current business banking statements (Must include All Pages)
Bank Account Verification & Disclosure (form provided, requires signature from the institution who
provides you the account in which funds will settle)
If there will be multiple locations per legal operating entity, an Additional Location Workbook will be
provided as a template in the application to list other locations. Additional Bank Account Verifications
and Cannabis License Uploads will be provided as well.
Merchant Website-Social Media Content Compliance Form. (form provided, requires signature)
Picture of Retail Store Front with Sign (If not available when doing a Google search)
Signed Merchant W-9

Step 2 - Fill Out the Application

Fill out and sign below

DISPENSARY MERCHANT INTAKE FORM
Agent
Submitted By
Phone
Paynetworx Contact
Company Information
Legal Name of Business*
Legal Address*
Address Registered with Secretary of State
Number of Locations*
City*
State*
Zip Code*
Customer Service Hours*

AM/PM Option

Until
until

AM/PM Option
DBA Name
DBA Address
Location of Business Operations
City
State
Zip Code
Website
Cannabis Lic. Exp Date*

MonthDayYear
Bus. Phone*
Fed Tax ID*
Business Start Date*

MonthDayYear
Type of Corporation*

Sole ProprietorshipPartnershipLLCCorporationNon-Profit
Currently Accept Credit Cards*

YesNo
Ownership Information
Name*

First NameLast Name
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
SSN*
DL#*
Expiration Date*

MonthDayYear
Date
State Issued*
Address (No PO Box)
City
State
Zip Code
Ever Been on Match of TMF List*

YesNo
Phone*
Title*
% of Ownership*
Payment Processing Information
Card Present (%)
Card Swiped (%)
Card Not Present (%)
Internet (%)
Mail / Phone Order (%)
B2B (%)
Total (%)
Processing Volume (Cash, Checks, ACH, etc.) ($)
Estimated TOTAL Monthly Volume
Monthly Visa/MC/Disc ($)
Monthly Amex Volume ($)
Average Ticket ($)
Max High End Ticket ($)
PIN Debit

YesNo
Personal Guarantor

YesNo
Products/Services Sold
Return/Refund Policy
Product Received

(Must equal 100%)
Time of Sale (%)
1-7 Days (%)
8-14 Days (%)
15-30 Days (%)
30+ Days (%)
Total (%)
Bank Name
Routing Number
Account Number
Flat Rate Pricing/Fees (For Agent Use Only)
Interchange Fees
Per Transaction Fees

Push to Card Fee: $2.95	ACH Fee: $2.95
Send Check Fee: $2.95	Gift Card Fee: $2.95
Vendor Pay B2B Fee: $2.95	Chargeback: $35.00 Per Item
	Return Check/ACH Fee: $35.00 Per Item

Monthly Statement Fee: $0.00	Monthly Minimum Fee: $500.00
Terminal Batch Fee: $0.00 Per Batch

Auto Batch

YesNo
Time of Batch

Hour Minutes

AM/PM Option
Manual

YesNo

Onsite Training Fee

	a	b
1
2

Additional Owner Information
Beneficial Owner (#2)
Name

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
SSN
DL#
Expiration Date

MonthDayYear
Date
State Issued
Address
City
State
Zip Code
Phone
% of Ownership
Title
Beneficial Owner (#3)
Name

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
SSN
DL#
Expiration Date

MonthDayYear
Date
State Issued
Address
City
State
Zip Code
Phone
% of Ownership
Title
Beneficial Owner (#4)
Name

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
SSN
DL#
Expiration Date

MonthDayYear
Date
State Issued
Address
City
State
Zip Code
Phone
% of Ownership
Title
Preferred Business Contact Person
Name*

First NameLast Name
Title*
Email*
example@example.com
Address
City
State
Zip Code
Phone*
Required Documents
Please upload the documents*

File Size Limit: 10MB
Cancelof
Terminal Ordering Information*
Does The Merchant Need To Order Terminals

YesNo
Terminals
QD4 WiFi or IP

$343 Each
Number of WiFi Terminals
Number of Ethernet IP Terminals
QD2 - 4G

$529 Each
Number of 4G Wireless Terminals
4G Service
Price Per Month/Device
One Time SIM Card Activation Fee / Per Device
* Terminal Prices Subject to Change Without Notice
Terminal Programming Options
Tip Format (Optional)

Dollars ($)PercentageNo TipCustom Tip Box 1Custom Tip Box 2Custom Tip Box 3
Do you need Clerk ID Activated

YesNo
EQUIPMENT AND 4G SERVICE COST
Total Terminal Cost
Total 4G Monthly Service Cost
TOTAL Upfront Cost of Equipment
Terminal Cost
CUSTOMER SUPPLIED TERMINALS
Number of QD2 Terminals
Number of QD4 Terminals
Total Downloads
Download Fee
$10 Per Terminal
- Please indicate type and number of each terminal requested. Also note that for all 4G enabled devices, a cellular service fee of $____ per
  terminal/station per month will apply along with a one-time $10.00 per terminal SIM CARD activation fee.
- Monthly Terminal Support & Encryption Fee of $_____ is charged for each terminal.
- Please note the total amount due for equipment specified and listed herein must be paid in full prior to being shipped to your location.
- Equipment Refunds: ALL EQUIPMENT SALES ARE FINAL AND NON-REFUNDABLE.
Privacy Fee To Consumer (Optional)
Privacy Fee To Consumer Type

% per transaction$ per transaction
Merchant receives 100% of this fee to offset their Processing Fee: Average % Fee is 1% up to 4% OR $1.50 to $5.00 per transaction.
Person Who Will Complete and is Authorized to Sign Electronic Document
Name

First NameLast Name
Email
example@example.com
Phone
NOTE: Processor will not accept partial applications. All documents must be submitted to Boarding, merchants will receive an email for review and eSignature from Boarding.

Underwriting may require additional documentation and/or information after this initial package has been submitted to Boarding.

Once the application is approved, which typically takes 7-10 business days, a second email will be sent to the merchant with login credentials for the Merchant Portal.

As the Agent/ISO of record; I understand that it is my responsibility to make sure all of the information in this document
regarding the Merchant is true and has been verified to be accurate as received by the Merchant. Furthermore, I have reviewed
all the costs related to this program to the Merchant and have verbally and in writing explained same to the Merchant to their
complete understanding. I also understand that along with this document and the Dispensary Checklist that all supporting
documents must be gathered and reviewed before sending the complete packet for Pre-Boarding to_______________________.

I acknowledge all of the above has been completed and adhered to the best of my ability and have I explained to
the merchant in detail all costs and requirements of this program.
Agent Name

First NameLast Name
Date Sent for Review

MonthDayYear
Date
Agent Notes, Comments, Special Requirements:
Signature*

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GETTING STARTED WITH MANGOPAZE

An Easy 2-Step Process

Step 1 - Gather Required Documents

The required documents depends on the type of business you have

Step 2 - Fill Out the Application

DISPENSARY MERCHANT INTAKE FORM

Company Information

Ownership Information

Payment Processing Information

Product Received

Flat Rate Pricing/Fees (For Agent Use Only)

Additional Owner Information

Beneficial Owner (#2)

Beneficial Owner (#3)

Beneficial Owner (#4)

Preferred Business Contact Person

Required Documents

Terminal Ordering Information*

Terminals

QD4 WiFi or IP

QD2 - 4G

Terminal Programming Options

EQUIPMENT AND 4G SERVICE COST

CUSTOMER SUPPLIED TERMINALS

Person Who Will Complete and is Authorized to Sign Electronic Document

A World Of Payments.

Simplified.