HomeMy WebLinkAboutOnline Payments RESOLUTION 2023-688
n'Fio�g ADOPTED DOC ID: 19341
THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2023-688 WAS
ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON
AUGUST 15, 2023:
RESOLVED that the Town Board of the Town of Southold hereby authorizes and directs
Supervisor Scott A Russell to enter into a"Purchase Processing Agreement"with Forte
Processing Systems, Inc. for processing online payments for various fees to the Town Clerks
Office, subject to the approval of the Town Attorney.
Denis Noncarrow
Southold Town Clerk
RESULT: ADOPTED [UNANIMOUS]
MOVER: Sarah E.Nappa, Councilwoman
SECONDER:Brian O. Mealy, Councilman
AYES: Nappa, Doroski,Mealy, Doherty, Evans, Russell
CO
csgforte COPY Merchant Application
Merchant's Legal Name:-'^ (erk
W So Department(DBA): l_!_S
Physical Street Address(No PO Boxes): 5 �•
City: C v+1 6 fid Q� rr 1 C / State:N y Zip Code:
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Phone: �5 - 1800 Fax: l0 J I C J- 6 (4 5
Customer Servipe/general Office Phoneumber.
Website:3 0 �old aw r, so\j
Name: Name:
Kl o n r LJ [CL_ e.n 0.
Business Phone: �S t - -1 G 5- 'S00 Business Phone: Q _ (a 5 _ LI 3 3
E-mail: .LA •v p pick R E-mail: `0.fJY o Id
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Name: t b �1 SeVendor Name:
Business Phone: lD _ _ '8 4 1 Contact Name: Contact Phone:
E-mail: \jCkrEmail:
Federal Tax ID: `'( ` r_ OFA 13�y Merchant Time Zone: Select Cut-Off Time: Select 1 a a
w lJ l 1 Gross Annual$Collected
Avg.Bill Amt.:$ Max.Bill Amt.:$ (Cash/Check/CC/Money Order):
Deposit Transit Routing/ Deposit Bank Account Information
ABA Number(9 Digits): V O (0(0-7 DDA/Checking Account#: �5 QOO
Debit Transit Routing/ Debit Bank Account Information
ABA Number(9 Digits): N, DDA/Checking Account
Internet(WEB) Visa ®MasterCard M Discover ❑AMEX ❑eCheck ❑All ❑ V400c Stand Alone❑Magtek iDynamo(Apple)
❑Phone(IVR) ❑Visa ❑MasterCard ❑Discover ❑AMEX ❑eCheck ❑All V400c w/Cables ❑Magtek uDynamo(Android)
❑Terminal(POS) ❑Visa ❑MasterCard ❑Discover ❑AMEX ❑All eDynamo Equipment Quantity:
at type of services or products are you accepting payments for?
Y S
Name: Din Phone Number: (p3 7�� _ Email: jS cdY ph(
❑Returned Check ❑Training ❑ Reporting ❑ IT ❑Accounting ❑ Notifications/Maintenance ❑ Dispute Mgmt. All
} hone Number: [ tD-51-` G5-1433 Email: jkt-j4,,,.he_ soqj-�je e OV
❑ Returned Check ®Training ❑ Reporting❑ IT ®Accounting
Notifications/Maintenance Dispute Mgmt. ❑ All
Name: Phone Number: (e 31-71.5- t&q 1 Email: Y jd
❑Retumed Check •Training Reporting L7 IT ❑Accounting p Notifications/Maintenance ❑ Dispute Mgmt. ❑ All
Name] ,x r Phone Number: (31- L,5' IRC>6 Email: ruA&er Uwn
❑Returned Check ❑ Training ❑ Reporting ❑ IT ❑Accounting ❑ Notifications/Maintenance ❑ Dispute Mgmt. 21-.All
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Version 11.17.2021
P
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forte ' Merchant Application
17
Should a Feld Be Collected on Does The Terminal Reduire*a
the Point of Sale Terminal. Static IP Address?
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Yes N6 Yes �/Mo
If Yes,Provide the Names of the Fields Receipt Header Information
to Be Collected-i.e.,Cashier ID or
Invoice Number
Name
Name
"Review and signKe-Prici Sche e
Signature: Date: J U'�
Printed Name: i � Title:
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Version 11.17.2021