Merchant Information

Legal Name of Business (as it appears on your tax return): *

Doing Business As (DBA) if applicable: *

Best Phone Number to Reach Applicant: *

Business Phone Number: *

Email Address: *

Contact Name

Business Website (if applicable:)

Confirm Email

Contact Title

Business Fax Number:

Business Address: *

City: *

Zip Code: *

Address Line 2

State: *

Owner Information

LAST NAME: *

TITLE

OWNERSHIP (%)

DATE OF BIRTH ( MM / DD / YYYY )

HOME ADDRESS

CITY

STATE

ZIP CODE

HOME PHONE #

SOCIAL SECURITY #

DRIVER LICENSE #

Driver License State: *

Dr.Lic. Exp Date: *

PERSONAL RESIDENCE

How long at this address?

Years:

Months:

Business Information

Description of Company (i.e. Cafes, Restaurants):*

Type of Ownership:*

Business Start Date ( MM / DD / YYYY )

State Filed

Merchant Type

Network Profile (VISA/MASTERCARD/DISCOVER/AMEX)

Swiped Credit Cards

Keyed Credit Cards

MO/TO

Internet

Merchant Receives Imprint on Keyed Transactions

Your Previous Card Processor

Reason For Change

Termination Date ( MM / DD / YYYY )

Other Reason For Change

Refund Policy

Refund Type

Refund Policy Days

Federal Tax Id Number of Company (Sole Ownership may use SSN): *

Would you like to Accept American Express? *

Name of the Bank you want your funds deposited into: *

Routing Number: *

Account Number: *

Total Monthly Bankcard Sales (estimated): *

I have verified my bank account number and routing number to be correct: *
Yes I have verified my bank account and routing number

Average Individual Sale Amount (estimated): *

If you need equipment reprogrammed please enter equipment name and model number:

Highest Sale Amount

Type of equipment you would like, if you selected to receive a free credit card terminal:

For Stationary Terminal please select if if you want it connected through Dial Up or IP.

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Merchant Information

Owner Information

Business Information

Equipment Information