Fill out this new client agreement form and we will complete setup.

Step 1 of 3

New Client Agreement and Information
Organization's Legal Name*
Organization's Name*
As it appears on registration page.
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Physical Address (if Different)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Organization's Logo*
Drop files here or
Submit your organization's logo with this form.
Please provide a clear logo for your account.
The logo will be placed against a white background.

(Note: jpeg, png or illustrator format is acceptable. Factor of 234 x 60 PNG file with transparent background is preferred.)
Organization's Website

ACH Direct Payment Authorization

Accounting Contact*

Name	Title	Email	Phone

Bank Name*
Name on Account*
Bank Routing #*
Checking Account #*
Set-Up Fee / Transaction Fee
You will be charged a one time setup fee of $100.00.

You're continued pricing model will be as follows:
1.8% + $.25 per transaction plus interchange and $.25 card authorization fee.* ACH Processing is also available. See Appendix for details.
Services
Check all that apply below:
Solutions:*
- SwiftGive™ Online and App Giving / TextGive (Premium Short Code Number, up to 3 keywords)
$50.00 a month
ReachNow
- Level I ($30 a month)
- Level II ($75 a month)
- Level III ($120 a month)
Send Outbound Text Message Alerts
Notes
Client
IN WITNESS WHEREOF, the parties have executed this Service Agreement effective on the date signed by Client.
Signature*
Printed Name:*
First Last
Title:*
Date*
Date Format: MM slash DD slash YYYY
mobileAxept North America, Inc.

Printed Name: David W. Richter
Title: Chief Executive Officer

Keyword Selection
Please indicate your Donor Management Software
(and fund code you use in association with each keyword)

Keyword Requests

Keyword	Description	Fund ID Num. or Code (If applicable)

These are the desired keywords your organization will have for users to text in. *More than three keywords for text may be subject to additional fees. You can leave these blank and wait to discuss with your account manager.

Keyword Requests

Keyword	Description	Fund ID Num. or Code (If applicable)

Keyword Requests

Keyword	Description	Fund ID Num. or Code (If applicable)

Key Contact Information
Please provide the following contact information it may be the same person.

Account Administrator

Name & Title	Mobile Phone	Direct Phone	Email Address

Technical Contact

Name & Title	Mobile Phone	Direct Phone	Email Address