MERCHANT PROCESSING APPLICATION - PPT
BUSINESS INFORMATION:
DBA Doing Business As Name
Business/Corporate Name: (as shown on your Income Tax Return)
Address
Location Address
Street Address Line 2
City
State
Zip
Address
Statement Mailing Address
Street Address Line 2
City
State
Zip
Business Fax Number
Email
example@example.com
Website
Bussines Phone Number
Bank Name
Name on Bank Account
Checking Account
Bank Routing
Federal Tax ID
TIN Type
EIN
SSN
Contact Name
Type of Merchant
Sole Proprietor
Partnership
LLC
Corporation
Non-Profit
Business Processing Category
Retail
Restaurant
MOTO
Internet
Merchandise/Services Sold:
Years in Business
Currently accept Visa/MasterCard/Discover/AXP?
Yes
No
Percent of Business: (must equal 100%)
Not Satisfied
Card Swipe:
Manually Keyed:
Phone/Mail Order:
Internet:
Avg Ticket
High Ticket
Avg Monthly Volume
High Monthly Volume
Transaction Descriptor to Appear on Cardholders Statement
Customer Service Phone Number to Appear on Cardholder's Statement
OWNERS AND OFFICERS:
List all owning 25% or more business equity. Use addendum to list additional
Name
Title
Applicants SS
Date of Birth
/
Month
/
Day
Year
Date
Equity Ownership
Address
Residence Address
Street Address Line 2
City State Zip
State / Province
Postal / Zip Code
Name
Title
Applicants SS
Date of Birth
/
Month
/
Day
Year
Date
Date of Birth
Equity Ownership
Residence Address
City, State, Zip
Phone Number
Name
Residence Address
City, State, Zip:
Date of Birth
/
Month
/
Day
Year
Date
SS
Discover Retained SE
PIN DEBIT ex STAR NYCE INTERLINK PULSE MAESTRO
Initials
PRICING SCHEDULE
Pricing
RETAIL
MOTO/INTERNET
Type a question
Not Satisfied
Transaction Fee:
Qualified discount rate:
Qualified discount rate (check card):
Merchant Principal or Corporate Officer Signature
Print Name
Date
/
Month
/
Day
Year
Date
Guarantor Signature
Print Name
Date
/
Month
/
Day
Year
Date
Merchant Name
Merchant Address
Merchant Phone
Signature
Name Title of Signatory
Date
/
Month
/
Day
Year
Date
Continue
Continue
Should be Empty: