HomeMy WebLinkAbout1 - Original Submission_ GP app RecDesk (Bremerton 2022)Phone: 877-994-6889
Email: team@govtportal.com
Fax: 770-804-2001
Web: www.govtportal.com
Govt Portal, Inc.
875 Old Roswell Rd. STE A-400
Roswell, GA 30076
Govt Portal appreciates the consideration for merchant services and electronic payment services. Upon
Completion of this application by the City/County/School, our team will follow up to ensure proper
implementation. As with every Govt Portal solution, there is no obligation to the City/County/School. Our
service can be canceled at any time, but we would appreciate thirty (30) days' notice.
General Information
Entity Name:
Department:
Location Street Address:
City: State: ZIP:
Location Phone: Web Address:
Contact Name: Contact Phone:
Contact Email: Fed Tax ID:
Finance Contact (if applicable): Tax Filing Name:
Entity Type (Select One):
Government Higher Education
Transaction Information
Anticipated Monthly Payment Card Volume:
Anticipated Average Payment Card Ticket:
Anticipated Highest Payment Card Ticket:
Description of products or services sold:
Service Acceptance and Fee Schedule
Pricing Preference (Select One):
Absorb Cost (monthly) 2.8% Pass Cost Along to the cardholder 3.0%
City of Bremerton
Parks & Recreation
680 Lebo Blvd.
Bremerton WA 98310
(360) 473-5305 www.bremertonwa.gov
Jeff Elevado (360) 473-5428
jeff.elevado@ci.bremerton.wa.us 91-6001231
4
25,000.00
150.00
5,000.00
Recreation Activity Registration, Park Rentals, Cemetery Fees
4
DocuSign Envelope ID: B953B4F8-8F27-4F1B-AF92-4DBCD57B32EF
Phone: 877-994-6889
Email: team@govtportal.com
Fax: 770-804-2001
Web: www.govtportal.com
Govt Portal, Inc.
875 Old Roswell Rd. STE A-400
Roswell, GA 30076
Acknowledgements
I understand that my bank will receive a micro deposit (under $1) as a test transaction, and that
amount will be refunded once the portal is live. (Please do not return the funds)
I have attached all applicable voided checks for deposits of transaction funds.
I have attached an employee badge confirming that I work for the city/county/school.
I have filled in, signed, and attached a W-9 form.
I understand that if the W9 information provided does not match what is listed on file with the IRS I may be
contacted to have this information corrected in the last quarter of the year and will need to provide a
corrected W9 to avoid withholdings.
The address information for the city/county/school is correctly listed above. If not please correct.
I acknowledge that GovtPortal is setting up a Credit Card Processing account with Priority
Payment Systems on behalf of my City/County.
GovtPortal will charge the city/county $0.00 for equipment, training, and program setup.
I acknowledge the daily batch totals will be deposited into the provided bank account within
two (2) business days.
If there is a block on your bank account, please check with your representative for a copy of the ACH ID to be
added to your bank account to allow for successful debiting and avoid ACH rejection. Please be advised all
accounts must allow debiting regardless of account type.
________________________________ desires to work with Govt Portal and wishes to utilize the GovtPortal
online payment feature. For this reason, the City grants permission to GovtPortal to access records (if
applicable) for the sole purpose of accepting payments. Govt Portal acknowledges all data is city property and
shall take all reasonable precautions to safeguard this asset. Govt Portal will treat all data received as
confidential and will release data to a third party only as instructed in writing by the City.
Signature_____________________________________________________ Date_______________
City of Bremerton
DocuSign Envelope ID: B953B4F8-8F27-4F1B-AF92-4DBCD57B32EF
6/1/2022