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Step 1: Merchant Application

Instructions:  Please complete all fields on the following application unless that directly do not apply to you. 

  1. Once the complete the electronic form and press the (General Merchant Application) button at the bottom, a .PDF form will be created for you to download. 
  2. You must print the form out, sign and date it and fax it back to: Fax: 866-660-5431 (toll free). 
  3. In addition to the completed application you need to fax a copy of the voided check from the bank you specified on the form below, which must be the same bank where you want credit card sales deposited, to the same fax#.
  4. Failure to complete the entire application will only delay your application.  Many fields are Required *.
  5. Press the Go to Step 2 once you have completed the form to your satisfaction.
General  Information      
Legal Business Name:*   Doing Business AS (DBA):
Federal Tax ID /Employer ID:*    -             Social Security Number (sole proprietor only):*      -    -      
Business Address(no PO Boxes):*   Mailing Address:
City/State/Zip:*   City/State/Zip
County:   Business Phone:
How Long?:  Years   Business Fax:
Contact Person Name:*   Number of Locations:
E-Mail Address:*   Number of Employees:
Do you have a Website?:
If Yes, Specify: 		  Time in Business: months
         
Business  Information      
Ownership Type:*
Other(Specify): 		  Primary Merchant Type:
Expected Maximum Monthly Sales:* $     Expected Avg. Transaction Size:* $  
Business Location:
 

  Marketing Methods:
Transaction Breakdown: Retail Swipped expected-  %   Customer Type: Businesss-to-Business(B-2-B) expected-  %
  Retail Keyed expected-  %     Businesss-to-Consumer(B-2-C) expected-  %
  Internet expected-  %     Total Must = 100 %
  Mail Order expected-  %      
  Total Must = 100 %      
Customer Return Policy:
  Average # of days until product delivered: days
Describe Product/Service:   Who performs product/service fulfillment?

Specify Fulfillment House information
      Name:
Address:
Phone:
Ever accepted cards previously?:
  Ever had a previous merchant account terminated?:

Former Merchant Acct#:   Explain why?:
         
Bank  Information      
Bank Name:*   Branch Name:
Bank Address:   Bank Contact Name:
City:*   Bank Phone:
State:*   Zip:    
Transit# (ABA Routing):*     Account# (DDA):*  
         
Principal 1      
Name:*     Title:
Ownership %:*  %   Date of Birth:*
Social Security #:*   Drivers License # / State:*
Residential Address:*   Own or Rent?:
City:*   How Long at Address:  
State:*  Zip:   Home Phone:
         
  Principal 2 (required if Principal 1 < 50% ownership)      
Name:     Title:
Ownership %:  %   Date of Birth:
Social Security #:   Drivers License # / State
Residential Address:   Own or Rent?:
City:   How Long at Address:  
State:  Zip:   Home Phone:
Human Verification:
  Reenter Validation Code: