Mercahant Application Form

You are on your way to increasing your sales and profits by accepting credit cards for your business. For your privacy and security, your account information is kept safe with the highest grade of commercially available encryption.

Please provide us with the information requested below to the best of your knowledge, fields that you don’t know or that you are not sure about please leave blank. Required items are marked with ( )

MERCHANT INFO

Type of Ownership Sole Proprietorship Partnership Corporation LLC Non-Profit LLP Government
Legal Name
DBA Name
Product service Sold
Tax id
Year Business was Started
Time Frame of Transaction Instant 0-7 days 8-14 days15-30 days Over 30 days
Total monthly Credit
card sales (estmited)
Sales Per Month
Ticket Price
Return & Refund Policies?
Would you like to accept American Express? Currently processing credit card? Have you ever had a credit card relationship terminated?
Yes Yes Yes
NO No No
Business Email
Website
Business Phone Number
Fax Number
Busienss address
City
State
Zip- Code

OWNER INFO

Full Name
Home Address
City
State
Zip-Code
Personal Phone Number
Social Security
Date of Birth
Owernship %
Fees Structure

Merchent Charge
Customer Charge
Account number
Routing
Bank Name
Name on bank account
Equipement

Please enter your SSN: