MERCHANT PROCESSING ONLINE APPLICATION

CREDIT CARD MACHINES CHECK READERS & OTHER TERMINALS

SUPPLIES & ACCESSORIES

MERCHANT ACCOUNT RATES & FEES

INTERNET PAYMENT PROCESSING

APPLY FOR A MERCHANT ACCOUNT

ON LINE APPLICATION

ABOUT US

PREFERRED VENDORS

ONLINE APPLICATION

BUSINESS INFORMATION
*BUSINESS NAME / CORPORATE NAME:
*DBA:
*ADDRESS:
*CITY:
*STATE, *ZIP:
*COUNTRY:
*TELEPHONE:
*ALT PHONE:
*BEST TIME TO CALL:
*FAX:
*WEBSITE URL:
*E-MAIL ADDRESS:
*U.S. FEDERAL TAX EIN: (OR SOCIAL SECURITY #):

LISTED OWNERS OR OFFICERS
OWNER#1
*FIRST NAME:
*LAST NAME:
*TITLE:
*SOCIAL SECURITY #:
*HOME PHONE:
*HOME ADDRESS:
*CITY:
*STATE, *ZIP:
*DRIVERS LICENSE NUMBER:
OWNER#2
*FIRST NAME:
*LAST NAME:
*TITLE:
*SOCIAL SECURITY #:
*HOME PHONE:
*HOME ADDRESS:
*CITY:
*STATE, *ZIP:
*DRIVERS LICENSE NUMBER:

MERCHANT PROFILE SECTION

ARE YOU A NEW OR EXISTING BUSINESS?

NUMBER OF YEARS IN BUSINESS

MERCHANT TYPE: CHECK ALL THAT APPLY

RETAIL OUTLET	RESTAURANT FOOD	HOME BUSINESS
MAIL ORDER	PHONE ORDER	TRADE FAIRS
INTERNET

* TYPE OF OWNERSHIP:

TYPE OF BUSINESS/GOODS OR SERVICES SOLD:

SALES PROFILE: (TOTAL 100%)

CREDIT CARDS SWIPED

CREDIT CARDS KEYED

* HOW DO YOU MARKET YOUR BUSINESS?: CHECK ALL THAT APPLY

NEWSPAPER / MAGAZINE	TELEVISION / RADIO	INTERNET
DIRECT MAIL / CATALOG	TELEMARKETING

HAVE YOU OR ANYONE ASSOCIATED WITH YOUR BUSINESS EVER BEEN TERMINATED AS A V/MC MERCHANT:

*HAVE YOU EVER DECLARED BANKRUPTCY:

IF SO, WAS IT DISCHARGED:

MERCHANT PROCESSING SET-UP

EQUIPMENT INFORMATION

TERMINAL TYPE:

HYPERCOM:

NURIT:

VERIFONE:

THALES TALENTO:

NEXTEL AIRCHARGE®:

SOFTWARE OR VIRTUAL TERMINAL TYPE:

EXTERNAL PRINTER TYPE:

EXTERNAL PIN PAD TYPE:

CHECK READER TYPE:

ARE YOU PURCHASING OR LEASING THE MACHINE:

PURCHASE

LEASE (NOT A COMMITMENT JUST A REQUEST FOR QUOTE)

TERMINAL PROGRAM:

SERVICE ENROLLMENT:

ALL SERVICES BELOW ARE AUTOMATICALLY INCLUDED IN STANDARD MERCHANT SET-UP. NO ADDITIONAL FEES FOR SET-UP OR RECURRING MONTHLY:

VISA& MASTER CARD

DISCOVER CARD

DEBIT AND CHECK CARDS
(WITH VISA/MASTER CARD LOGO)

AMERICAN EXPRESS

J.C.B. CARD

THE BELOW SERVICES ARE NOT INCLUDED BECAUSE THEY REQUIRE ADDITIONAL MONTHLY FEES. FOR APPLICABLE FEES SEE THE RATES AND FEES PAGE.

CHECK THE BOXES BELOW FOR THE ADDITIONAL SERVICES, WHICH YOU REQUIRE.

DEBIT CARD SERVICES

CHECK GUARANTEE

ACH BANK INFORMATION:
YOUR MERCHANT ACCOUNT WILL DEPOSIT FUNDS FROM CREDIT CARD TRANSACTIONS DIRECTLY INTO THE CHECKING ACCOUNT PROVIDED BELOW.
BANK NAME:
BANK PHONE:
TRANSIT# (ABA Routing)
ACCOUNT # (DDA)
UNDERWRITING CRITERIA:
*AVERAGE TICKET SIZE:
*HIGHEST TICKET:
*ESTIMATED MONTHLY VOLUME:
THANK YOU FOR YOUR BUSINESS. PLEASE CLICK THE SUBMIT BUTTON AND YOU WILL BE CONTACTED BY A MEMBER OF OUR STAFF WITHIN 24 HOURS TO FINALIZE THE ESTABLISHMENT YOUR ACCOUNT.
*Required Fields