Merchant Services Application Form
Corporate / Legal Name
*
DBA Name
Ownership Type
*
Please Select
Individual
Partnership
Corporation
Government
LLC
Non-profit
Publicly Traded
Legal Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is your DBA (Doing Business As) information same as Corporate/Legal?
*
Yes
No
Business Location (if different than legal address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
When was your business founded?
*
-
Month
-
Day
Year
Date
Where do you prefer to receive mail?
DBA
Legal
Building Type
Shopping Center
Office Building
Industrial Building
Residence
Building Ownership
Owns
Rents
Area Zoned
Commercial
Industrial
Residential
Square Footage
0-500
501-2500
2501-5000
5001-10000
10,000+
Customer Service Telephone Number
*
Format: (000) 000-0000.
Website Address
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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
Address & Contact Information
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Ownership %
*
Is this the individual you want to list as management?
Yes
No
Have you (your business or any principal) filed bankruptcy?
Business Bankruptcy
Personal Bankruptcy
Never
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Processing Information
This section pertains to information about your business’s credit card processing and acceptance.
Bank Account Number
*
Bank Routing Number
*
Does this business currently accept credit cards?
Yes
No
Monthly Volume
*
Average Transaction Amount
*
Max Transaction Amount
*
Describe your product/service.
*
Which payments would you like to accept?
Primary Sales Method
In-person (card present)
Mail/Phone (card not present)
Internet/eCommerce (card not present)
Percentage of Sales from International Customers
Please describe your refund and return policy.
*
Please list equipment and/or software used to process cards (point-of-sale, terminal, payment gateway, etc.)
Inventory Maintained
On-Site
Off-Site (i.e. Warehouse)
3rd Party Fulfillment Center
Service Only (No Products Sold)
Are there any other companies involved in shipping or fulfilling products/services (i.e. fulfillment center)?
Yes
No
Are there any other companies involved in shipping or fulfilling product/service (i.e. fulfillment center)?
Yes
No
Do you offer recurring and time-extended services (subscriptions, memberships, recurring plans, etc.)?
Yes
No
Notes (Optional)
Submit
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