Merchant Processing Application Business NamesLegal Name (for Sole Propritorships; enter Principle Name)(Required) DBA(Required) Business Type (Legal Entity i.e.: Corporation, LLC, etc.)(Required) State Registered DD dash MM dash YYYY Date Registered DD dash MM dash YYYY Business DetailsType of Owner(Required)ProfitNon-ProfitFederal Tax ID (EIN) Verify Federal Tax ID (EIN) Banking InformationBank Name(Required) Bank Account Name(Required) Bank Routing Number(Required) Bank Account Number(Required) Business AddressAddress(Required) City(Required) State(Required) Zip(Required) Mailing AddressSame as business address Same as businesses address Mailing Address(Required) City(Required) State(Required) Zip(Required) Contact InformationContact First Name*(Required) Contact Last Name*(Required) Business Phone*(Required)Business Fax*(Required)Corporate Phone*(Required)Corporate Fax*(Required)Customer Service PhoneBusiness Email*(Required) Verify Business Email*(Required) Federal Tax ID Will be Provided after Submission Federal Tax ID Will be Provided after Submission Number of Locations Business Hours Date Registered DD dash MM dash YYYY Contact Mailing Address(Required) City(Required) State(Required) Zip(Required) Ownership InformationOwner Name(Required) Owner Email(Required) Percent of Business Owned(Required) Date Registered DD dash MM dash YYYY SS#(Required) DL#(Required) Issuing State(Required) Home Address(Required) City(Required) State(Required) Zip(Required) Additional Owner Information, if Applicable Yes No Owner Name(Required) Owner Email(Required) Percent of Business Owned(Required) Date Registered DD dash MM dash YYYY SS#(Required) DL#(Required) Issuing State(Required) Home Address(Required) City(Required) State(Required) Zip(Required) Prior Merchant AccountIf yes, who was your processor?(Required) Previous Merchant Number(Required)Prior Merchant Account ClosureHow you ever been terminated from a processor before Yes No Merchant TypeMerchant Type(Required)Type of Product(s)/Service(s) Sold (type a few to get suggestions)(Required)Business Name Processing BreakdownPlease provide a breakdown of how credit orders will be received. Please use estimates. Total must equal 100%.Retail Swiped/EMV Retail Keyed % Internet % MOTO % Total% Processing LimitsAverage Ticket High Ticket Monthly Bank Card Volume Monthly Amex Volume Methods Of MarketingMethod of Marketing Direct Mail Internet Magazine or Catalog Newspaper Outbound Telemarketing TV or Radio Third Party Cardholder Data Service UsageMerchant uses Third Party Cardholder Data Usage Yes No Seasonal MerchantIs your Business seasonal ? Yes No First Name Last Name Business Title Ownership % SSN/ITIN Verify SSN/ITIN SSN will be provided after submission SSN will be provided after submission This is an ITIN This is an ITIN Address(Required) City(Required) State(Required) Zip(Required) Own / Rent(Required)Select a ResidentialOwn / RentPrinciple Email(Required)Verify Principle Email(Required)Cell Phone(Required)Date of Birth DD dash MM dash YYYY Driver License # Driver License # Driver License State(Required)Select a StateOrlandNYWBusiness Website* Primary Contact Mobile Phone*(Required)Amex DirectOwner Name Discover DirectDiscover Direct Merchant Number Percent of Business Owned SS# DOB MM slash DD slash YYYY DL# Issuing State Home Address*(Required) Financial InformationGross Annual Sales Average Annual Credit Card Volume: Highest Ticket AmountAverage Ticket AmountProperty InformationOwn or Rent Location Landlord Name Landlord PhoneLease TermLease Start Date MM slash DD slash YYYY Δ
