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Merchant Services Application
Funding Specialist
agent email
Business Information
Business Legal Name
*
DBA Same as Legal Name?
DBA Name
*
Tax ID Number
*
Company Type
*
Please Select
Limited Liability Company
S Corporation
C Corporation
Partnership
Sole Proprietor
Industry Type
*
Please Select
Advertising
Agriculture
Apparel
Automotive
Banking
Beauty / Nail Salon
Biotechnology
Chemicals
Communications
Construction
Consulting
Education
Electronics
Energy
Engineering
Entertainment
Entertainment Industry
Environmental
Equipment Sales
Farming / Agriculture
Finance
Finance, Insurance & Real Estate
Food & Beverage
Government
Health Care
Healthcare
Hospitality
Insurance
Janitorial
Legal Services / Law Firm
Machinery
Manufacturing
Media
Miscellaneous Business Services
Not For Profit
Other
Pharmacy
Photography
Real Estate
Recreation
Restaurants & Drinking Establishments
Retail
Shipping
Technology
Telecommunications
Transportation
Transportation/Logistics;Manufacturing;Exporting
Utilities
Wholesale / Distributor
State of Incorporation
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
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
Monthly Credit Card Volume
*
Average Credit Card Transaction
*
High Credit Card Transaction
*
Business Start Date
*
-
Month
-
Day
Year
Business Phone Number
*
Format: (000) 000-0000.
Business Description / Industry Type
*
Business Address
*
Owner Information
Name
*
First Name
Last Name
Mobile Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Social Security Number
*
SSN
Home Address
*
Signature
*
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