Business Information  
Legal Name Of Business
Doing Business As (Prints on Credit Card Statment)
Web Site Address E-Mail Address
    Re-Enter e-mail address
Street Address
City State Zip
Mailing Address
City State Zip
Type Of Business
Percent Of Business
Must Be 100%
Keyed W/ Imprint %
Type Of Owner Ship
Corporation
Partnership
Sole-Proprietor
Non Profit
Contact Name
Normal Business Hours
Card Swiped %
Keyed W/O Imprint %
Federal Tax ID #
Social Security No
Business Telephone
Business Fax
NO. of Location Age Of Business
 
Ownership Information
Principle No.1 Percentage of Ownership % Combined Ownership Must be Greater then 50%
Principle Legal Name
Date Of Birth
mm/dd/yy
Social Security
Drivers License Sate Expiration Date
XXmm/dd/yy ( e.g. NY01/05/99)
Home Phone
Residence Address
City State Zip
Own Rent How Long
Name of nearest relative not living with you
Address City State Phone
Principle No.2 Percentage of Ownership%
Principle Legal Name
Date Of Birth
mm/dd/yy
Social Security
Drivers License State Expiration Date
XXmm/dd/yy ( e.g. NY01/05/99)

Home Phone
Residence Address
City State Zip
Own Rent How Long
Name of nearest relative not living with you
Address City State Phone
 
References
Bank Account Phone Contact
Trade Account Phone Contact
Trade Account Phone Contact
 
Services Ordered
Processing Information Monthly Merchant Account Fee
Monthly Volume Average Ticket Highest Ticket

Card Processing Check Box to Order
Visa/Master Card
Y N
 
Debit Card
Y N
 
Wireless Access
Y N
 
American Express
Y N
 
Online/ACH Checking
Y N
 
Discover
Y N
 
Diners
Y N
 
Checking Service
ECA Guar.
MVP Club - $11.95/Mo
Y N
Merchant Value Plan (MVP)-Free Equipment Replacement and monthly supply Kit
 
Equipment Information
Program (Check One) Retail Restaurant Lodging Mail Order
 
Advertising & Sales Method
Write "NA" If not applicable.
1) How are Product or Service Sold? Store Front

Mail

Phone

Internet

Website URL

Other

2) How does your business advertise? Store Front

Mail

Phone

Internet

Other

(Must Submit ad copies sample of flyers, catalogues, Price list, yellow pages etc.)
3) Shiping Service Fed Ex

Ups

Airborne

Other
4) Where is Inventory Stocked ? Merchant Location

Other
5)Fulfillment Center Services -
(If used please list name, address, phone and services provided)
Yes No      
6) Is there a charge for restocking a returned item? Yes No Amount $  
7) How long does your services continue after the card is charged Days (90 day maximum)
8) Guarantee or Warranty Days (90 day maximum)
9) List the top product or service sold Sales Price

 

10) Comment/ Web site logo's/Passwords/URL's/IP Address (For Under Construction web site)

Have you processed merchant Bank card before? Yes No  
If yes with whom Under what business Name

 

Reason of leaving previous marchant bank card processor (if terminated please submit a latter of explanation with this application)