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1-855-955-6111
ONLINE MERCHANT APPLICATION
* All fields are required.
Persons opening an account on the behalf of a legal entity must provide the following information:
MERCHANT NAME (DBA OR TRADE NAME)
*
LOCATION ADDRESS
*
CITY
*
STATE
*
ZIP
*
CONTACT PHONE
*
CONTACT EMAIL ADDRESS
*
------------------------------------------------------------------------------------------------------
CORPORATE / LEGAL NAME
*
CORPORATE ADDRESS
*
CITY
*
STATE
*
ZIP
*
CONTACT PHONE
*
FAX NUMBER
*
FEDERAL TAX ID#
*
------------------------------------------------------------------------------------------------------
YEARS IN BUSINESS
*
WEBSITE ADDRESS
*
NUMBER OF LOCATIONS
*
DOES THIS LOCATION CURRENTLY ACCEPT VISA/ MASTERCARD/DISCOVER® NETWORK/AMERICAN EXPRESS®?
*
Yes
No
CURRENT PROCESSOR
*
MUST PROVIDE 2 MONTHS PREVIOUS PROCESSOR STMTS
BY CHECKING THIS BOX, MERCHANT OPTS OUT OF RECEIVING FUTURE COMMERCIAL MARKETING COMMUNICATIONS FROM AMERICAN EXPRESS
*
Yes
INDICATE VISA, MASTERCARD, DISCOVER, AXP CARD OR PAYPAL TYPES NOT TO ACCEPT
*
------------------------------------------------------------------------------------------------------
PLEASE CHOOSE MAILING ADDRESS
*
DBA
LEGAL
------------------------------------------------------------------------------------------------------
VISA/MASTERCARD/DISCOVER
AVERAGE TICKET
*
MAXIMUM TICKET
*
MONTHLY VOLUME
*
AMERICAN EXPRESS
AVERAGE TICKET
*
MAXIMUM TICKET
*
MONTHLY VOLUME
*
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(a) PRINCIPALS:
The following information for each individual, if any, who, directly or indirectly, through any contract, arrangement, understanding, relationship or otherwise, owns 25 percent or more of the equity interests of the legal entity listed above: (Please provide copy of driver’s license for each signing principal)
1. PRINCIPAL NAME:
FIRST
*
MIDDLE
*
LAST
*
DATE OF BIRTH
*
SSN
*
% OWNERSHIP
*
TITLE
*
HOME ADDRESS
*
CITY
*
STATE
*
ZIP
*
HOME PHONE
*
DRIVERS LICENSE # / PASSPORT #
*
EXP DATE
*
2. PRINCIPAL NAME:
FIRST
*
MIDDLE
*
LAST
*
DATE OF BIRTH
*
SSN
*
% OWNERSHIP
*
TITLE
*
HOME ADDRESS
*
CITY
*
STATE
*
ZIP
*
HOME PHONE
*
DRIVERS LICENSE # / PASSPORT #
*
EXP DATE
*
HAVE MERCHANT OR OWNERS / PRINCIPALS EVER FILED:
*
BUSINESS BANKRUPTCY
PERSONAL BANKRUPTCY
NEVER FILED
HAVE MERCHANT OR OWNERS / PRINCIPALS EVER FILED: (If yes, please explain)
*
------------------------------------------------------------------------------------------------------
BANK ACCOUNT INFORMATION
ATTACH VOIDED CHECK
NAME ON THE ACCOUNT:
*
ROUTING NUMBER
*
ACCOUNT NUMBER
*
------------------------------------------------------------------------------------------------------
SALES METHOD (MUST EQUAL 100%)
RETAIL SWIPED %
*
KEYED %
*
ECOMM %
*
MOTO %
*
Submit Application
