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 LocationsBusiness HoursDate 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 NameProcessing BreakdownPlease provide a breakdown of how credit orders will be received. Please use estimates. Total must equal 100%.Retail Swiped/EMVRetail Keyed %Internet %MOTO %Total%Processing LimitsAverage TicketHigh TicketMonthly Bank Card VolumeMonthly Amex VolumeMethods 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 NameLast NameBusiness TitleOwnership %SSN/ITINVerify SSN/ITINSSN 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 NameDiscover DirectDiscover Direct Merchant NumberPercent of Business OwnedSS#DOB MM slash DD slash YYYY DL#Issuing StateHome Address*(Required)Financial InformationGross Annual SalesAverage Annual Credit Card Volume:Highest Ticket AmountAverage Ticket AmountProperty InformationOwn or Rent LocationLandlord NameLandlord PhoneLease TermLease Start Date MM slash DD slash YYYY Δ
