Free Online Application
(Complete all fields - Insert N/A in fields that do not apply )

 Business Name(s)

 d/b/a Name:
  Legal Name:
 Street Address:
 City:
 State: Zip:
 Years at This Address:
 Phone:
 Email Address:
 Federal Tax ID:
EIN or SSN
 Mailing Address:
 City:
 State: Zip:
 Web Address :
 Fax:
 Cell Phone:
Contact Name :

Business Profile

 Owner Type:
(Select One)		  Industry Type: (Select One)
 Currently Accept Visa/MasterCard
 at this or other business?*:

 Merchandise/Services Sold:

 Previous Business Name:
  Ever Terminated for Card Services:
 

 Business Start Date (month/year):
 Number of Locations:

 Prior Bankruptcy:
 Seasonal:

*Must Submit Three (3) Most Recent Bankcard Statements
 Gross Yearly Sales:
  Average Ticket Size:
 Monthly Bank Card Volume:  Highest Ticket:
 Describe High Ticket Item:

Transaction Method (= 100%)

Sales Method (= 100%)
 Swiped, (with signature):
 Store Front:
 Keyed (card present, w/ signature):
 Off Premises:
 Mail/Telephone Sales:
 Mail/Telephone Sales:
Trade Show:
Internet:
 Other:
 Total must equal 100%
 Total must equal 100%

Current Bankcard Processing Information

 Current/Previous Processor:
 Merchant Number:
 Processor Phone Number:
 Reason for Change:
  Current Equipment (if any):
 AMEX:
 Existing #:
 Discover:
 Existing #:

Depository Bank Information

 Depository Bank:
  Phone Number:
 Bank Address (local branch):
  City:
 State: Zip:
 Account Number:
  Routing Number:

Owners or Officers

 Name:
  Title:
 SS#:  Phone:
 % Ownership:
  Date of Birth:
 Drivers License #:
  State:
 Home Address (no PO Box):
 City:
State:  Zip:
 # of Years at address:

 Name:
  Title:
 SS#:  Phone:
 % Ownership:
  Date of Birth:
 Drivers License #:
  State:
 Home Address (no PO Box):
 City:
State:  Zip:
 # of Years at address:

Comments or Questions


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