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Merchant Application

Merchant Account Application.

Business Information
Business Name (DBA if applicable):  
Business Legal Name:  
Date Business Established (MMYYYY):  
Contact Name: 
Contact Phone #:  
Business Phone Number:  
Business Address 1:  
Business Address 2:  
Business City:  
Business State: 
Business Zip Code:  
Mailing Address Name: 
Mailing Address Line 1:  
Mailing Address Line 2:  
Mailing City:  
Mailing State: 
Mailing Zip Code:  
Business Email:  
Business Fax Number:  
Website Address:  
Federal Tax ID:  
Products or services being sold:  

Merchant History
Ever Accepted Credit Cards Before ?    No  Yes
If Yes, Name of Processor:  
Ever Had an Account Cancelled?   No   Yes
If Yes, Name of Processor:  
Date of Cancellation:  
Reason for Cancellation:  

Business Checking
Bank Name: 
Checking Account #:  
Transit Routing #:  
Years Open:  
Bank Address:  
Bank City:  
Bank State: 
Bank Zip Code:  

Business Owners/Officers/Partners
Name of Primary Owner/Officer/Partner: 
Social Security #:  
Percent Owned:  %
Phone #:  
Owner/Officer Since:  
Residence Address:  
Zip Code:  
Name of Secondary Owner/Officer/Partner: 
Social Security #:  
Percent Owned:  %
Phone #:  
Owner/Officer Since:  
Residence Address:  
Zip Code:  

Transaction Information
Estimated Monthly Sales:  
Average Transaction Amount:  
   Visa®/MasterCard®  American Express®
  Discover/Novus®  JCB®  ACH/Check

2.10% of sales volume and .30 per transactionSet-up fee:NONEMonthly minimum fee:NONE
Corporate/Purchasing card downgrades at 1.90 and .20 (Amex included)Reporting fee:NONEGateway set-up fees:NONE
$20 chargebackDeposit fee:NONEGateway monthly fees:NONE
$0.25 credit  Gateway authorization fees:NONE

Merchant Acknowledgement
By checking the acknowledgement box below, Merchant: 1) Certifies that all information provided in this Application is correct, 2) Understands additional information may be needed before this Application can be fully evaluated, 3) Has reviewed and accepted all terms of the attached Merchant Agreement and Pricing Schedule, 4) Authorizes credit and debit entries to Merchant’s business checking account, 5) Agrees to notify Bank or Company if any information in this Application changes, 6) Understands that incomplete or inaccurate information may result in account denial or cancellation, 7) Agrees that in the event the Merchant Agreement is modified, continuing to process transactions constitutes acceptance of the revised MerchantAgreement, 8) Authorizes the request of consumer and business credit reports from consumer and business credit reporting agencies, and verification of all information contained in this Application.

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