Merchant Services Application Form

Merchant Services Application Form

Please provide detailed information about your business operations and payment processing needs.
Business Name
Business Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Contact Person Full Name

First NameLast Name
Business Email Address
example@example.com
Business Phone Number
Please enter a valid phone number.
Website URL:
Business Type (LLC, Corp, Sole Proprietor, etc.):
Federal EIN / Tax ID:
Business Start Date:
Type of Business
Do you have a business license?

YesNo
Does your business operate from a physical location, online, or both?

OnlineBrick and MortarBoth
What percentage of your sales are Card-present (in-person): blanks
What percentage of your sales are Card-not-present (online/phone/mail): blank
Industry/Business Vertical:
Are you a seasonal business?

YesNo
If yes, which months do you operate?
Is your business home-based?

YesNo
Do you sell internationally? If Yes! What Countries?
Monthly Credit Card Sales Volume (Estimated):
Average Ticket Amount:
Highest Ticket Amount:
Do you currently accept credit/debit card payments?

YesNo
If yes, please specify your current payment processor
What payment methods do you want to accept?
What types of payments do you need to accept?

In-Store (POS)OnlineMobileInvoicingRecurring Billing
Are you interested in eliminating credit card fees through Dual Pricing?

YesNoNot Sure
Do you need a terminal or POS system?

YesNo
If yes, preferred type:

CountertopWirelessMobileVirtual Terminal
Do you sell high-risk or regulated products (CBD, tobacco, adult, etc.)?
If yes, please specify:
Do you require online payment gateway integration?

YesNo
Do you use a website shopping cart or platform (e.g., Shopify, WooCommerce, Wix)?
Any additional services you're interested in?

Business FundingGift CardsLoyalty ProgramseCommerce Integration
Owners Information
Owner/Principal Name:
Title:
Ownership Percentage:
SSN (for identity verification):
Date of Birth:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Co-Owner/Principal Name:
Title:
Ownership Percentage:
SSN (for identity verification):
Date of Birth:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Describe any special payment processing needs or additional services required
Owners Signature

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Date

MonthDayYear
Date
Co-Owners Signature

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Date

MonthDayYear
Date
Should be Empty:

Merchant Services Application Form

Owners Information