Application for Merchant Services
1. Legal Information
Legal Business Name
*
Hint: Tab key jumps to next field.
Legal Address
*
Unit Number
Type
P.O. Box
Suite
Legal Zip
*
Legal Phone Number
*
Legal Fax
2. DBA Information (about your location)
DBA Company Name
*
Hint: Shift+Tab key jumps to previous field.
DBA address is
same as legal
DBA Address
*
Unit
Type
Unit
Suite
Zip Code
*
DBA Phone is
same as legal
DBA Phone
*
Ext.
optional
DBA Fax is
same as legal
DBA Fax
E-mail
*
Confirm E-mail
*
Website
Customer Service Phone is same as DBA Phone
Yes
No
Customer Service Phone
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3. Business Contact
Years Owned
*
Months Owned
*
Notification Preference
*
Please Select
Fax
Email
how should we send you chargebacks?
Chargeback Fax
-
Area Code
Phone Number
Chargeback Email
card disputes will be emailed here
Contact Person Title
*
Please Select
CEO
Co-Owner
Controller
Corporate Secretary
Director
Executive Director
Financial Officer
General Manager
General Partner
IRS/Tax Contact
Limited Partner
Manager
Member
Owner
President
Secretary
Secretary/Treasurer
Senior VP
Vice President
Contact Person
*
First Name
Last Name
Contact Phone
*
Phone Ext.
4. Bankruptcy
Business Bankruptcy
*
Please Select
Yes
No
Has your business ever declared bankruptcy?
Business Bankruptcy Discharge Date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Personal Bankruptcy
*
Please Select
Yes
No
Have you ever declared bankruptcy?
Personal Bankruptcy Discharge Date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
5. How do you file your business with the IRS?
Business name as filed
*
Tax address filed with IRS is:
*
Same as Legal above
Same as DBA above
Different than above
Bus. Address for IRS
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Tax Person
*
Tax Person's Position
Title, Dept. or Company
Do you prefer 1099 form sent by Email?
*
Please Select
Yes, send via email only.
No, send postal mail only.
Where to email your 1099
Tax Exempt
*
No
Yes
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6. Type of Business
Ownership
*
Please Select
Corporation - Non-Profit
Corporation - Private
Corporation - Publicly Traded
Government Entity
LLC
Ltd Liability Partnership
Ltd Partnership
Partnership
Political Organization
Professional Association
Sole Proprietorship
Trust
What kind of business is it?
Business Type
*
Please Select
Retail
Retail With Tips
Restaurant
Mail Order/Phone Order (MOTO)
Internet
Lodging
SuperMarket
Utility
Pharmacy
Business to Business
Fuel
Tax ID Type
*
Please Select
EIN
SSN
TIN
required, numbers only
Tax ID Number
*
no dashes (-) numbers only
Enter your MCC if known
Merchant Category Code
or select MCC from list
Please Select
0742 - Veterinary Services
0763 - Agriculture Cooperative
0780 - Landscaping and Horticultural Services
1520 - General Contractors-Residential and Commercial
1711 - Heating, Plumbing and Air Conditioning Contractors
1731 - Electrical Contractors
1740 - Masonry, Stonework, Tile Setting and Plastering
1750 - Carpentry Service
1761 - Roofing, Siding, Sheet Metal Work Contractors
1771 - Concrete Work Contractors
1799 - Special Trade Contractors
2741 - Miscellaneous Publishing and Printing
2791 - Typesetting, Plate Making and Related Services
2842 - Specialty Cleaning and Polishing
3366 - Budget Rent-A-Car
3370 - Rent-A-Wreck
3389 - Avis Rent-A-Car
3393 - National Car Rental
3501 - Holiday Inn
3502 - Best Western Hotels
3504 - Hilton Hotels
3508 - Quality Inn
3509 - Marriot
3510 - Days Inn
3515 - Rodeway Inn
3516 - La Quinta Inn
3562 - Comfort Inns
3565 - Relax Inn
3613 - Microtel Inn
3615 - Travelodge
3617 - Americas Best Value Inn
3621 - Suburban Extended Stay
3622 - Merlin Hotels
3631 - Sleep Inn
3637 - Ramada Inn
3638 - Howard Johnson
3640 - Hyatt Hotels
3644 - Econo Lodge
3649 - Radisson
3650 - Red Roof Inns
3657 - Oberoi Hotels
3660 - Knights Inn
3665 - Hampton Inns
3684 - Budget Host Inn
3687 - Clarion Hotels
3700 - Motel 6
3709 - Super 8 Motels
3715 - Fairfield Inn and Suites
3724 - Inter Nor Hotel
3728 - Bally Hotel & Casino
3750 - Crowne Plaza Hotels
3751 - Homewood Suites
3770 - Springhill Suites
3789 - Smugglers Notch Resort
4011 - Railroads
4111 - Local/Suburban Commuter Passenger Transportation
4112 - Passenger Railways
4119 - Ambulance Services
4121 - Taxicabs/Limousines
4131 - Bus Lines
4214 - Motor Freight Carriers, Trucking
4215 - Courier Services
4225 - Farm Products, Refrigerated Goods, Household Goods
4411 - Cruise Lines
4457 - Boat Rentals and Leases
4468 - Marinas, Marine Service and Supplies
4511 - Airlines, Air Carriers
4582 - Airports, Flying Fields, Airport Terminals
4722 - Travel Agencies and Tour Operators
4784 - Toll and Bridge Fees
4789 - Transportation Services
4812 - Telecommunications Equipment/'Telephone Sales
4814 - Telecommunication Services
4816 - Computer Network
4821 - Telegraph Services
4829 - Wire Transfer Money Orders
4899 - Cable and Other Pay Television Services
4900 - Utilities-Electric, Gas, Water, Sanitary
5013 - Motor Vehicle Supplies and New Parts
5021 - Office and Commercial Furniture
5039 - Construction Materials
5044 - Photographic, Photocopy, Microfilm Equipment
5045 - Computer and Computer Peripheral Equipment
5046 - Commercial Equipment
5047 - Medical Supplies
5051 - Metal Service Centers
5065 - Electrical Parts and Equipment
5072 - Hardware, Equipment and Supplies
5074 - Plumbing and Heating Equipment
5085 - Industrial Supplies
5094 - Precious Stones and Metals
5099 - Durable Goods
5111 - Printing/Writing Supplies
5113 - Industrial/Personal Service Paper
5122 - Drug Store
5131 - Piece Goods, Notions, and Other Dry Goods
5137 - Men's, Women's and Children's Uniforms
5139 - Footwear
5169 - Chemicals and Allied Products
5172 - Petroleum and Petroleum Products
5192 - Books, Periodicals and Newspapers
5193 - Florists Supplies, Nursery Stock and Flowers
5198 - Paints, Varnishes and Supplies
5199 - Nondurable Goods
5200 - Home Supply Warehouse
5211 - Lumber and Building Material Stores
5231 - Glass, Paint and Wallpaper Stores
5251 - Hardware Stores
5261 - Nurseries, Lawn and Garden Supply Stores
5271 - Mobile Homes Dealers
5300 - Wholesale Clubs
5309 - Duty Free Stores
5310 - Discount Stores
5311 - Department Stores
5331 - Variety Stores
5399 - Miscellaneous General Merchandise
5411 - Grocery Stores, Supermarkets
5422 - Freezer and Locker Meat Provisioners
5441 - Candy, Nut and Confectionery Stores
5451 - Dairy Products Store
5462 - Bakeries
5499 - Misc Food-Specialty, Markets, Convenience
5511 - Automobile and Truck Dealers
5521 - Automobile and Truck Dealers (Used)
5532 - Automotive Tire Stores
5533 - Automotive Parts, Accessories Stores
5541 - Service Stations
5542 - Automated Fuel Dispensers
5551 - Boat Dealers
5561 - Recreational and Utility Trailers
5571 - Motorcycle Shops and Dealers
5592 - Motor Home Dealers
5598 - Snowmobile Dealers
5599 - Miscellaneous Automotive, Aircraft and Farm Equip
5611 - Mens and Boys Clothing and Accessories Stores
5621 - Womens Ready to Wear Store
5631 - Womens Accessory and Specialty Shops
5641 - Childens and Infants Wear Stores
5651 - Family Clothing
5655 - Sports Apparel, Riding Apparel Stores
5661 - Shoe Stores
5681 - Furriers and Fur Shops
5691 - Men And Women Clothing
5697 - Tailors, Seamstresses, Mending
5698 - Wig and Toupee Stores
5699 - Misc Apparel and Accessories Shop
5712 - Furniture, Home Furnishings and Equipment Stores
5713 - Floor Covering Stores
5714 - Drapery, Window Covering and Upholstery Stores
5718 - Fireplace, Fireplace Screens and Accessories
5719 - Misc Home Furnishings Specialty Stores
5722 - Household Appliance Stores
5732 - Electronic Stores
5733 - Musical Instruments/Sheets
5734 - Computer Software Stores
5735 - Record Stores
5811 - Caterers
5812 - Eating Places Restaurants
5813 - Drinking Places, Bars, Taverns, Nightclubs
5814 - Fast Food Restaurants
5912 - Pharmacies
5921 - Package Stores-Beer, Wine and Liquor
5931 - Used Merchandise Stores, Secondhand Stores
5932 - Antique Shops
5933 - Pawn Shops
5935 - Wrecking and Salvage Yards
5937 - Antique Reproductions
5940 - Bicycle Shops
5941 - Sporting Goods
5942 - Book Stores
5943 - Stationary Stores, Office and School Supply Stores
5944 - Jewelry Stores, Watches, Clocks, and Silverware
5945 - Hobby,Toy and Game Shops
5946 - Camera and Photographic Supply Stores
5947 - Gift, Card, Novelty and Souvenir Shops
5948 - Luggage and Leather Goods Stores
5949 - Sewing, Needlework, Fabric and Piece Goods
5950 - Glassware, Crystal Store
5960 - Direct Marketing-Insurance
5962 - Direct Marketing-Travel Related
5963 - Door to Door Sales
5964 - Direct Marketing-Catalog Merchant
5965 - Direct Marketing
5966 - Direct Marketing-Outbound
5967 - Direct Marketing-Inbound
5968 - Direct Marketing-Subscription
5969 - Direct Marketing
5970 - Artist's Supply and Craft Shops
5971 - Art Dealers
5972 - Stamp and Coin Stores
5973 - Religious Goods Stores
5975 - Hearing Aids
5976 - Orthopedic Goods-Prosthetic Devices
5977 - Cosmetic Stores
5978 - Typewriter Stores
5983 - Fuel Dealers-Fuel, Oil, Wood Coal
5992 - Florists
5993 - Cigar Stores and Stands
5994 - News Dealers and Newsstands
5995 - Pet Merchandise
5996 - Swimming Pool/Equipment/Supplies
5997 - Electric Razor Store
5998 - Tent and Awning Shops
5999 - Miscellaneous and Specialty Retail Stores
6010 - Financial Institutions-Manual Cash Advance
6011 - Financial Institution-ATM
6012 - Financial Institutions-Merchandise and Services
6051 - Non-Financial Inst-Foreign Currency,Money Orders
6211 - Security Brokers/Dealers
6300 - Insurance Sales, Underwriting, and Premiums
6513 - Real Estate Agents and Managers Rentals
7011 - Lodging-Hotels, Motels, Resorts, Reservations
7012 - Timeshares
7032 - Sporting and Recreational Camps
7033 - Trailer Parks and Campgrounds
7210 - Laundry, Cleaning, and Garment Services
7211 - Laundries-Family and Commercial
7216 - Dry Cleaners
7217 - Carpet Upholstery Cleaning
7221 - Photographic Studios
7230 - Barber and Beauty Shops
7251 - Shoe Repair Shops, Shoe Shine, Hat Cleaning
7261 - Funeral Services and Crematories
7273 - Dating and Escort Services
7276 - Tax Preparation Service
7277 - Counseling Services-Debt, Marriage, Personal
7278 - Buying/Shopping Services, Clubs
7296 - Formal Wear Rentals/Costumes
7297 - Massage Parlors
7298 - Health and Beauty Spas
7299 - Other General Services
7311 - Advertising Agency/Services
7321 - Consumer Credit Reporting Agencies
7332 - Blueprinting and Photcopying Services
7333 - Commercial Photography, Art and Graphics
7338 - Quick Copy, Reproduction and Blueprinting Service
7339 - Stenographic and Secretarial Support Services
7342 - Exterminating and Disinfecting Services
7349 - Cleaning and Maintenance, Janitorial Services
7361 - Employment Agencies, Temporary Help Services
7372 - Computer Programs Service
7375 - Information Retrieval Services
7379 - Computer Maintenance/Repair
7392 - Management, Consulting, and Public Relations Servi
7393 - Detective Agencies, Security Sys, Armored Cars
7394 - Equipment Rental and Leasing
7395 - Photofinishing Laboratories, Photo Development
7399 - Business Services
7512 - Car Rental Agencies
7513 - Truck and Utility Trailer Rental
7519 - Motor Home and Recreational Vehicle Rental
7523 - Automobile Parking Lots and Garages
7531 - Automotive Body Repair Shops
7534 - Tire Retreading and Repair Shops
7535 - Automotive Paint Shops
7538 - Automotive Service Shops
7542 - Car Wash
7549 - Towing Services
7622 - Electronics Repairs Shops
7623 - Air Conditioning and Refrigeration Repair Services
7629 - Electrical and Small Appliance Repair Services
7631 - Watch, Clock and Jewelry Repair
7641 - Reupholstery and Furniture Repair
7692 - Welding Repair
7699 - Miscellaneous Repair Shops and Related Services
7812 - Telephone Headsets
7829 - Motion Picture and Video Tape Production
7832 - Motion Picture Theatres
7841 - Video Tape Rental Stores
7911 - Dance Halls, Studios and Schools
7922 - Theatrical Producers, Ticket Agencies
7929 - Bands, Orchestras and Misc Entertainers
7932 - Billiard and Pool Establishments
7933 - Bowling Alleys
7941 - Commercial Sports, Professional Sports
7991 - Tourist Attractions and Exhibits
7992 - Golf Courses-Public
7993 - Video Amusement Game Supplies
7994 - Video Game Arcades
7995 - Betting, Casino Chips, Off-Track Betting, Wagers
7996 - Amusement Parks, Circuses and Carnivals
7997 - Clubs - Country
7998 - Aquariums, Seaquariums, Dolphinariums
7999 - Recreation Services
8011 - Doctors
8021 - Dentists, Orthodontists
8031 - Osteopaths
8041 - Chiropractors
8042 - Optometrists, Opthamologists
8043 - Opticians, Optical Goods and Eyeglasses
8049 - Chiropodists, Podiatrists
8050 - Nursing and Personal Care Facilities
8062 - Hospitals
8071 - Medical and Dental Laboratories
8099 - Medical Services and Health Practitioners
8111 - Attorneys
8211 - Elementary and Secondary Schools
8220 - Colleges, Universities, Professional Schools
8241 - Correspondence Schools
8244 - Business and Secretarial Schools
8249 - Vocational and Trade Schools
8299 - Schools and Educational Services
8351 - Child Care Services
8398 - Charitable and Social Service Organizations
8641 - Civic, Social and Fraternal Associations
8651 - Political Organizations
8661 - Religious Organizations
8675 - Automobile Associations
8699 - Membership Clubs
8734 - Testing Laboratories
8911 - Architectural, Engineering and Surveying Services
8931 - Accounting, Auditing and Bookkeeping Services
8999 - Professional Services
9211 - Court Costs, Alimony and Child Support
9222 - Fines
9223 - Bail and Bond Payments
9311 - Tax Payments
9399 - Government Services
9402 - Postal Services-Government Only
Merchant Category Code
Description
*
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Save and Continue
7. Ownership
Owner 1
*
First Name
Last Name
Owner 1 DOB
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Owner 1 SSN
*
% Ownership
Res. Street #
*
residence street number
Direction
Please Select
North
South
East
West
North West
North East
South West
South East
ex. N, SW, E
Residence Street Name
*
ex. broadway (no po box)
Street Type
Please Select
ALLEY
ANNEX
ARCADE
AVENUE
BAYOO
BEACH
BEND
BLUFF
BOTTOM
BOULEVARD
BRANCH
BRIDGE
BROOK
BURG
BYPASS
CAMP
CANYON
CAPE
CAUSEWAY
CENTER
CIRCLE
CLIFF
CLUB
COMMON
CORNER
COURSE
COURT
COVE
CREEK
CRESCENT
CREST
CROSSING
CROSSROAD
CURVE
DALE
DAM
DIVIDE
DRIVE
ESTATE
EXPRESSWAY
EXTENSION
FALL
FERRY
FIELD
FLAT
FORD
FOREST
FORGE
FORK
FORT
FREEWAY
GARDEN
GATEWAY
GLEN
GREEN
GROVE
HARBOR
HAVEN
HEIGHTS
HIGHWAY
HILL
HOLLOW
INLET
ISLAND
ISLE
JUNCTION
KEY
KNOLL
LAKE
LAND
LANE
LIGHT
LOAF
LOCK
LODGE
LOOP
MALL
MANOR
MEADOW
MEWS
MILL
MISSION
MOTORWAY
MOUNT
MOUNTAIN
NECK
ORCHARD
OVAL
OVERPASS
PARK
PARKWAY
PASS
PASSAGE
PATH
PIKE
PINE
PLACE
PLAIN
PLAZA
POINT
PORT
PRAIRIE
RADIAL
RAMP
RANCH
RAPID
REST
RIDGE
RIVER
ROAD
ROUTE
ROW
RUE
RUN
SHOAL
SHORE
SKYWAY
SPRING
SPUR
SQUARE
STATION
STRAVENUE
STREAM
STREET
SUMMIT
TERRACE
THROUGHWAY
TRACE
TRACK
TRAFFICWAY
TRAIL
TUNNEL
TURNPIKE
UNDERPASS
UNION
VALLEY
VIADUCT
VIEW
VILLAGE
VILLE
VISTA
WALK
WALL
WAY
WELL
ex. blvd
Unit #
ex. 2A
Residence Zip
*
5 digits only
Residence Phone
*
Personal Guarantor
Yes
Driver's License State
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Driver's License
*
numbers or letters only
Expiration Date
*
Please select a month
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Issue Date
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Year
Is there another Owner?
*
Yes
No
About Owner 2
This section is required if owner 1 is less than 50%
Owner 2
First Name
Last Name
Owner 2 DOB
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Month
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2
3
4
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7
8
9
10
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1920
Year
Owner 2 SSN
2nd Owner %
Res. Street #
residence street number
Direction
Please Select
North
South
East
West
North West
North East
South West
South East
ex. N, SW, E
Residence Street Name
ex. broadway (no po box)
Street Type
Please Select
ALLEY
ANNEX
ARCADE
AVENUE
BAYOO
BEACH
BEND
BLUFF
BOTTOM
BOULEVARD
BRANCH
BRIDGE
BROOK
BURG
BYPASS
CAMP
CANYON
CAPE
CAUSEWAY
CENTER
CIRCLE
CLIFF
CLUB
COMMON
CORNER
COURSE
COURT
COVE
CREEK
CRESCENT
CREST
CROSSING
CROSSROAD
CURVE
DALE
DAM
DIVIDE
DRIVE
ESTATE
EXPRESSWAY
EXTENSION
FALL
FERRY
FIELD
FLAT
FORD
FOREST
FORGE
FORK
FORT
FREEWAY
GARDEN
GATEWAY
GLEN
GREEN
GROVE
HARBOR
HAVEN
HEIGHTS
HIGHWAY
HILL
HOLLOW
INLET
ISLAND
ISLE
JUNCTION
KEY
KNOLL
LAKE
LAND
LANE
LIGHT
LOAF
LOCK
LODGE
LOOP
MALL
MANOR
MEADOW
MEWS
MILL
MISSION
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NECK
ORCHARD
OVAL
OVERPASS
PARK
PARKWAY
PASS
PASSAGE
PATH
PIKE
PINE
PLACE
PLAIN
PLAZA
POINT
PORT
PRAIRIE
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REST
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ROW
RUE
RUN
SHOAL
SHORE
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SPUR
SQUARE
STATION
STRAVENUE
STREAM
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SUMMIT
TERRACE
THROUGHWAY
TRACE
TRACK
TRAFFICWAY
TRAIL
TUNNEL
TURNPIKE
UNDERPASS
UNION
VALLEY
VIADUCT
VIEW
VILLAGE
VILLE
VISTA
WALK
WALL
WAY
WELL
ex. blvd
Unit #
ex. 2A
Res. Zip Code
5 digit only
Residence Phone
*
Personal Guarantor
Yes
Personal Guarantor May Be Required for Approval
Please Select
Owner 1
Owner 2
Public Corporation
Private Corporation
Government
Public Utility
Note: PG may only be waived for certain public or private corporations, public utilities or government offices.
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8. About Your Sales
Have you accepted credit cards before?
*
No
Yes
Your existing Merchant ID:
ex: 543684 5555 000 000
Seasonal Only Business?
*
No
Yes
Mark months your business is open or closed:
Open
Closed
January
February
March
April
May
June
July
August
September
October
November
December
# Locations
*
Do you bill before shipment?
*
No
Yes
Do you use 3rd party order fulfillment?
*
No
Yes
Clearly state your customer refund policy:
*
refund/return policy must be clearly stated on invoice or at time of sale.
Equipment
*
Please Select
I need a Terminal or POS
I need to process by phone
I need to process on mobile device
I need to process on PC/Mac (virtual terminal)
I have a POS
I have a Verifone VX510
I have a Verifone VX510 Dual Comm (internet+dial)
I have a Verifone VX510LE
I have a Verifone VX570
I have a Verifone 3730
I have a Verifone 3740
I have a Verifone 3750
I have a Verifone Tranz
I have a Hypercom T7P
I have a Hypercom T7Plus
I have a Hypercom T4205
I have a Hypercom T4220
I have a Hypercom T4000 series dual comm (IP+dial)
I have a Wireless Terminal
Other - my terminal is not listed here
I need a solution not listed here
Please tell us how you'll be taking credit cards
How do you process transactions? (must add up to 100%)
*
Swiped
Manual Key with Imprint
MOTO (Card Not Present)
Internet (eCommerce)
Total:
0
/
100
$ Average Ticket (receipt)
*
numbers only
$ Monthly Credit Card Sales
*
numbers only
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9. Bank Deposit
Name of Bank where we deposit your funds
*
ex. County Credit Union
Account Type
*
Please Select
Checking
Savings
Bank GL
ex. checking/savings
Bank Routing Number
*
numbers only
Account Number
*
numbers only
Confirm Account Number
*
numbers only
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