Merchant Services Application Form
Corporate / Legal Name
*
DBA Name
Ownership Type
*
Please Select
Individual
Partnership
Corporation
Government
LLC
Non-profit
Publicly Traded
Type a question
Legal Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
When was your business founded?
*
-
Month
-
Day
Year
Date
EIN Number
*
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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
*
Driver's License State
Expiration Date
*
-
Month
-
Day
Year
Date
Date of Birth
*
-
Month
-
Day
Year
Date
Social Security Number
*
Address & Contact Information
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Email
*
example@example.com
Ownership %
*
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Processing Information
This section pertains to information about your business’s credit card processing and acceptance.
Does this business currently accept credit cards?
Yes
No
Monthly Volume
*
Average Transaction Amount
*
Describe your product/service.
*
Primary Sales Method
In-person (card present)
Mail/Phone (card not present)
Internet/eCommerce (card not present)
Do you offer recurring and time-extended services (subscriptions, memberships, recurring plans, etc.)?
Yes
No
Notes (Optional)
Submit
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