First Name Last Name Company Name Phone Number E-Mail Website

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Step 2

Merchant Information

Legal Name of Business :

Doing Business As (DBA) (if applicable):

Best Phone Number to Reach Applicant:

Company Contact First Name :

Company Contact Last Name :

E-mail Address :

Business Website Address (if applicable) :

Business Phone Number :

Fax Number :

Business Street Address :

Business Suite # (if applicable) :

Business City :

Business State :

Business Zip Code :

Owner Information

Owner's First Name :

Owner's Last Name :

Home Phone :

Home Address :

Home Apartment # (if applicable) :

City :

State :

Zip :

% of Ownership :

Date of Birth :

Social Security :

Business Information

Describe Product or Service Sold (i.e. I sell flowers) :

Type of Ownership :

Tax Id :

Year Business was Started :

What is The Time Frame from Transaction to Delivery ?
Please use best estimates , Must equal 100%

0 - 7 days

8 - 14 days

15 - 30 days

Over 30 days

Return and Refund Policies?

Total Monthly Credit Card Sales (estimated) :

Average Individual Credit Card Sale Amount (estimated) :

Please provide a breakdown of how credit card orders will be received,
Please use best estimates , Must equal 100%

Internet

Telephone

Mail order

Face-to-face where card is swiped through terminal

Would you like to accept American Express?

Yes No

Are you now processing or have you ever processed MasterCard and/or Visa?

Yes No

Have you ever had a credit card relationship terminated?

Yes No

If yes, name of processor(s)

If yes, provide explanation

After completing the application and clicking the submit button you will be taken to Docusign to review your application and electronically sign it.

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Step 2

Merchant Information

Owner Information

Business Information