Merchant Application Form
Please fill out the form below to apply as a merchant with us.
Sales Agent
*
Sales Manager
Legal Business Name
*
EIN #
*
Ownership Type
*
Please Select
Sole Prop
LLC
INC
Type of Business
*
Please Select
Retail
Wholesale
E-commerce
Service Provider
Manufacturing
Other
DBA Name
*
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Website
Years in Business
*
Owner Full Name
*
First Name
Middle Name
Last Name
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Social Security #
*
Date of Birth
*
Drivers License # / State
*
Bank Name
*
Routing #
*
Account #
*
Annual Credit Card Volume
*
Annual Cash Volume
*
% Swiped / Keyed / Online
*
Equipment Subscription Price
Equipment Info
*
Pricing Structure
*
Please Select
Cash Discount (dual pricing)
Interchange +
Pricing Fees
*
Please Select
Dual 3.99%
Dual 3.5%
IC+ .50
IC+ .25
EBT / FNS# (yes or no)
*
Pin Debit (no if cash discount)
*
Tips (Y/N)
*
Server Numbers (Y/N)
*
Auto Batch Time
*
Communication Type
*
Please Select
Ethernet
Wifi
Analog
Drivers License
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Voided Check
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Business License
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Misc Info
Authorized Signature
*
Submit Application
Submit Application
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