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Merchant Account Application
Sorry, only U.S. based companies/merchants are eligible for this program at this time.
Business Information
Legal Business Name:
Doing Business As:
 
Contact Information
Contact Name:
Email Address:
Mailing Address:
Phone Number:
City / State / Zip:
  
Fax Number:
Country:
 
 
 
 
 
 
 
Billing Address is same as Mailing Address
 
 
Billing Address:
Website URL:
City / State / Zip:
  
# Of Locations:
Country:
Goods/Services Sold:
Time in Business:
Monthly Sales:
Average Sale Amount:
Current Ownership:
Years  Months  

 


 

Do you currently accept credit cards?  Yes No
Have you ever had a credit card merchant account terminated?   Yes No

 

If you answered "Yes" above, please explain:
Ownership Information
Type of Ownership:
Federal Tax ID#:

Principal One
Principal Two
Name:
Name:
Title:
Title:
% Of Ownership:
% Of Ownership:
Social Security Number:
Social Security Number:
Drivers License Number:
Drivers License Number:
Date Of Birth:
(mm/dd/yy)
Date Of Birth:
(mm/dd/yy)
 
 Home Address is same as Mailing Address
 
 Home Address is same as Mailing Address
Street Address:
Street Address:
City/State/Zip:
  
City/State/Zip:
  
Phone:
Phone:
Primary Residence?
Own Rent
Primary Residence?
Own Rent
If "Rent", please complete the landlord info below:
 
If "Rent", please complete the landlord info below:
 
Landlord Name:
Landlord Name:
Contact:
Contact:
Street Address:
Street Address:
City/State/Zip:
  
City/State/Zip:
  
Phone:
Phone:
References
Trade Reference 1 Name:
Trade Reference 1 Name:
Contact:
Contact:
Street Address:
Street Address:
City/State/Zip:
  
City/State/Zip:
  
Phone:
Phone:
Account # (if applicable):
Account # (if applicable):

Bank Reference Name:
Contact:
Phone:
Account #:
Bank Information
Bank Name:
Contact:
Street Address:
City/State/Zip:
  
Depository Account #:
Bank Routing Number (9 digits):
Phone:
 
 
Additional Information
Total Sales Breakdown
 
Total Credit Card Sales
 
Business To Business %:
Business To Business %:
Business To Consumer %:
Business To Consumer %:
 
Total MUST = 100%
 
Total MUST = 100%
Total MUST = 100%

Time Frame For Delivery Of Products/Services
 
0-7 Days %:
8-14 Days %:
15-30 Days %:
Over 30 Days %:
Total MUST = 100%

Who performs fulfillment??
Direct Vendor
If Vendor, Vendor Name:
Vendor Address:
Vendor Phone:
...

Describe the transaction, from order taking to fulfillment.
...

How will you protect your business from cardholder fraud?
...

If your business does recurring billing, please explain why:
Payment Information
Billing Statement Address is same as Principal One information.
Name on Credit Card:
Billing Statement Address:
City:
State/Province:
 
Zip Code:
Country:
Credit Card Type:
Card Number:
Expiration Date (mm/yy):
I authorize the sum of $125.00 USD to be charged to the above account upon approval.
 
Your application will be reviewed within 2 business days. Upon approval, a representative will contact you with more info. In the event your application is declined,
you will not be charged a setup or application fee. If you have questions regarding this application, please contact .

 

Continue

 

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