Merchant Application

Type of Account Applying For Credit Card
ACH E-check Services
   
Business Information
D/B/A name
Legal name
Address
City
State   Zip    
Contact name
Contact Email address
Corporate phone
Corporate fax
Web address
Total # Locations
Ownership: Proprietorship
Partnerhsip
Corporation
LLC
NonProfit
Type of Business

Retail
Wholesale
Restaurant
Lodging
Convenience Store
Supermarket
MO/TO
Home Business
Trade Fairs
Outside Sales/Services
Internet Only
Date established
Does this location currently accept Visa/MasterCard? Yes     No
Average Ticket
Size of high ticket
Monthly average volume
                Or
Annual average volume
Sales Method (Total must be 100) Retail Swiped %
Hand Key No Imprint %
Hand Key With Imprint & Signature %
   

Non Bank Card
Do you need accounts in addition to Visa/Mastercard, and whether or not you have current accounts.

American Express
Do you have a current account? Yes No
Discover
Do you have a current account? Yes No
Diners/Cart Blanche
Do you have a current account? Yes No
   
Site Information Retail Store Front
Office/Warehouse
Residential
Other:
   
Owner – Officer Information – Two Are Required  
Owner/Officer Name #1
Title
Home Address
City
State   Zip    
Home Phone
% of ownership
   
Owner/Officer Name #2
Title
Home Address
City
State   Zip    
Home Phone
% of ownership
   
Have principals filed bankruptcy during the past two years? Yes     No
   
Trade References - Two Are Required  
Trade Reference Name #1
Contact
Phone
Account #
   
Trade Reference Name #2
Contact
Phone
Account #
   

Note:
Please double check all your information for accuracy and completeness before submitting. We only need one form; please don’t submit multiple times.

A hard copy of the merchant processing agreement (MPA) must also be submitted. We’ll call you within 24 hours of your submittal to collect additional information, since we don’t ask for anything confidential via internet. After our chat, we’ll send you your completed application for approval, and once you approve it, we’ll start business! Submitting your form puts you under no obligations. Feel free to call or email us beforehand with any questions.