Merchant Services Application Form
Corporate / Legal Name
*
DBA Name
*
EIN
*
Ownership Type
*
Please Select
Individual
Partnership
Corporation
Government
LLC
Non-profit
Publicly Traded
Legal Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is your DBA (Doing Business As) information same as Corporate/Legal?
*
Yes
No
Business Location (if different than legal address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
When was your business founded?
*
-
Month
-
Day
Year
Date
Where do you prefer to receive mail?
*
DBA
Legal
Customer Service Telephone Number
*
Website Address
*
Products and/or Services Sold
*
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Principal Information
Please list all principals who, directly or indirectly, through any contract, arrangement, understanding, relationship or otherwise, own 25% or more of the equity interests of the legal entity listed in this application.
Owner Name
*
First Name
Last Name
Title
*
Please Select
CEO
Chairman
Co-Owner
Controller
Director
General Manager
Office Manager
Owner
Partner
President
Treasurer
Vice President
Driver's License Number
*
SSN
*
Expiration Date
*
-
Month
-
Day
Year
Date
Date of Birth
*
-
Month
-
Day
Year
Date
Address & Contact Information
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Email
*
example@example.com
Ownership %
*
Is this the individual you want to list as management?
*
Yes
No
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Processing Information
This section pertains to information about your business’s credit card processing and acceptance.
Select Your Payment Solution
*
In-Person
Email Invoice
On-the-Go
Online
Bank Account Number
*
Bank Routing Number
*
Does this business currently accept credit cards?
*
Yes
No
Monthly Volume
*
Average Transaction Amount
*
Max Transaction Amount
*
Describe your product/service.
*
Which payments would you like to accept?
Primary Sales Method
In-person (card present)
Mail/Phone (card not present)
Internet/eCommerce (card not present)
Percentage of Sales from International Customers
Please describe your refund and return policy.
*
Please list equipment and/or software used to process cards (point-of-sale, terminal, payment gateway, etc.)
Notes (Optional)
Voided Check
*
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Driver License
*
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Merchant Processing Statement (optional)
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