Merchant Processing Application and Agreement
Application Date
/
Month
/
Day
Year
Date
Client's Business Name (Doing Business As)
*
Client's Corporate/Legal Name (Must match IRS income tax filing)
*
Location Address
*
City
*
State
*
Zip
*
Corporate Address (If Different Than Location; Otherwise write "Same")
*
City
State
Zip
Location Phone
*
Customer Service Phone (if different)
Location Fax
Contact Name
*
Contact Phone
*
Prior Security Breach?
*
Yes
No
Business Email
*
example@example.com
D&B # (DUNS #), if applicable
Business Website Address
Multiple Locations?
*
Yes
No
If yes, how many locations?
Fed Tax ID # (Must match IRS income tax filing)
*
Tax Type
Tax Filing Name
*
Send retrieval/chargeback requests to
*
Corporate Address
Location Address
Date Business Started
*
/
Month
/
Day
Year
Date
Length Current Ownership
*
Send monthly statements to
*
Corporate Address
Location Address
Do Not Mail
Type of organization
*
Sole Prop
Partnership
LLC/LLP
C Corp
S Corp
Govt. (Local/State/Federal)
501c/Tax Ex.
State Filing:
I certify that I am a foreign entity / nonresident alien.
If checked, please attach IRS Form W-8
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OWNER/PARTNER/OFFICER 1
Name
*
Title
*
Ownership %
*
Home Address
*
City
*
State
*
Zip
*
Telephone
*
Driver License/ID #
*
Issued State
*
DL/ID Exp Date
*
/
Month
/
Day
Year
Date
Social Security
*
Date of Birth
*
/
Month
/
Day
Year
Date
Email Address
*
example@example.com
OWNER/PARTNER/OFFICER 2
Does anyone else own 25% or more of the organization?
*
Yes
No
Name
Title
Ownership %
Address
City
State
Zip
DL/ID Exp Date
/
Month
/
Day
Year
Date
Social Security
Date of Birth
/
Month
/
Day
Year
Date
Email Address
example@example.com
Prior Bankruptcies?
*
Yes
No
If yes, what type of bankruptcy?
*
Business
Personal
Business and/or Personal Date Discharged
/
Month
/
Day
Year
Date
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Business Type
Retail
Restaurant
Internet
Government
Lodging
Supermarket
Mail/Telephone Order
Petroleum
Utilities
Healthcare
Education
QSR
Charity/Non Profit
B2B
Other
Requested Monthly Payment Card Volume (amount processed via credit card per month, in dollars)
*
Requested Average Payment Card Ticket (average sale amount, in dollars)
*
Requested Highest Payment Card Ticket (largest sale amount you expect, in dollars)
*
What percent of sales fall under the following four categories? Card Present Swiped (%)
*
Card Present Not Swiped(%)
*
MOTO (%). This includes sales over the phone, mail, virtual terminal, etc.
*
Ecommerce (%)
What percent of your sales are to the following three categories? Sales Direct to Consumers (%)
Sales to Business (%)
Sales to Govt. (%)
Days to Delivery (If service provided immediately, type "0")
Seasonal Merchant?
Yes
No
If seasonal, what months do you operate?
Previous Processor
*
Reason For Leaving
*
Description of products or services sold
Bondsmen servicers
Describe your return policy
As required by law
Deposit Bank Name
*
Routing #
*
Account #
*
ACH Method (most merchants prefer combined)
Combined
Individual
Fees Bank Name (If same as deposit, type "same")
*
Routing
Account
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Which cards would you like to accept?
Visa Credit
Visa Non-PIN Debit
MasterCard Credit
MasterCard Non-PIN Debit
Discover Network
American Express
Discount Plan
Tiered Basic
Flat Rate
Pass Through I/C
Discount Payment Method - Daily
Assessments - Included
Brand Fees - Included
Discount Fee (%)
Per Item Fee ($)
"X" to opt out of marketing
PCI Non-Compliance fee up to $24.95
Retrieval Fee
ACH Reject Fee
Chargeback Fee
Accept EBT Cash Benefit
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Application Type
Retail
Fraud Check (last 4-digits)
Yes
No
Yes
No
Yes
No
Server/Clerk
AVS + CVV2
Purchasing Card
Auto Close
Y
N
If yes, time?
Terminal
Pinpad
Printer
VAR
Product Name
QUANTITY
1
New Order
New Order
Manufacturer/product/version of PC/Internet Software
*
Do you use any third party to store data?
No
Signature of Merchant
*
Title
*
Print Name of Signer
*
Date
*
/
Month
/
Day
Year
Date
Signature of other merchant owning 25%+ of company
Title
Print Name of Signer
Date
/
Month
/
Day
Year
Date
Personal Guarantee Signature
*
Print Name
*
Date
*
/
Month
/
Day
Year
Date
Business Legal Name
*
Signature
*
Please Print Name of Signer
*
Title
*
Date
*
/
Month
/
Day
Year
Date
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Section 1: Merchant Application Information (Must match information in Merchant Application): Date Application Signed (by Authorized Signer named below)
*
/
Month
/
Day
Year
Date
Merchant Legal Name
*
Merchant Federal Tax ID (as it appears on income tax return)
*
Merchant Address
*
Merchant State of Formation/Incorporation
*
Merchant Entity Type
*
Beneficial Owner Legal Name
*
Title
*
Ownership %
*
Address
*
Individual’s Home (Street) Address (No P.O. Box)
Street Address Line 2
City, State, Zip
State / Province
Postal / Zip Code
Date of Birth
*
/
Month
/
Day
Year
Date
Individual has Social Security Number
Yes
Social Security No. (SSN)/Individual Taxpayer Identification No. (ITIN)
*
The undersigned Authorized Signer, listed above as a Beneficial Owner or Control Prong, who has signed the Merchant Application on behalf of the Merchant, hereby certifies that he/she is authorized to open accounts for the Merchant at financial institutions, that all information provided above about the Merchant legal entity is complete and correct and that, to the best of his/her knowledge, all information provided above about each individual listed above is complete and correct and there is no individual who directly or indirectly owns 25% or more of the Merchant legal entity’s equity interests whose information is not provided above. The Authorized Signer and the Processor’s Representative, each hereby certify that the information listed above regarding the identity and the identification document of each individual listed above, is complete and correct and was personally observed on the indicated document.
*
Date
*
Print Name
*
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