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Merchant Services Application
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About
Applications
Company Formation
Merchant Services Application
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Merchant Services Application
Merchant Services Application
Business Information
Business Name
Do you have a U.S. Business Address?
Yes
No
Address
City
State
Zip Code
Business Email
Business Phone Number
Business Website
Employer Identification Number
Bussiness Start Date
Number of Locations
Do you have a Doing Business As ("DBA") / Trade Name?
Yes
No
DBA / Trade Name
Address
City
State
Zip Code
Business Entity Type
Sole Proprietorship
Partnership
Limited Liability Company
Corporation
Non-Profit
Do you currently accept Credit Cards or Debit Cards?
Yes
No
Owner Information
First Name
Middle Name
Last Name
Email
Phone Number
Title
Social Security Number
Date of Birth
Ownership %
Total Ownership %
Address
City
State / Province
Zip Code / Postal Code
Business Owner - 2
First Name
Middle Name
Last Name
Email
Phone Number
Social Security Number
Date Of Birth
Ownership %
Total Ownership %
Business Owner - 3
First Name
Middle Name
Last Name
Email
Phone Number
Social Security Number
Date Of Birth
Ownership %
Total Ownership %
Business Owner - 4
First Name
Middle Name
Last Name
Email
Phone Number
Social Security Number
Date Of Birth
Ownership %
Total Ownership %
Credit Card Processing Information
Card Present %
Card Swiped %
Internet %
Card Not Present %
Mail / Phone Order %
B2B %
Monthly Visa/MC/Disc
Monthly Amex Volume
Average Ticket Price
Max High End Ticket Price
PIN Debit
Yes
No
Personal Gurantor
Yes
No
Products/Services Sold
Return/Refund Policy
Product Received
Time of Sale
1-7 Days
8-14 Days
15-30 Days
30+ Days
U.S. Bank Name
Rouing #
Account #
Equipment Information
Do you have an equipment information?
Yes
No
Terminal (Make/Model)
Purchase New
Gateway / Virtual Terminal (If applicable)
Terminal Cost (If new)
EBT
Yes
No
Cost (If Yes)
Batch
Auto
Manual
Discount
Daily
Monthly
Accept Tips
Yes
No
Deposit
Standard
NextDay
Auto- Batch Time
IC+ Pricing / Fees (For Agent Use Only)
%BPS
Auth
Trans
Pin Mnth
PIN %BPS
PIN TXN
Batch
Monthly
Month Min
PCI
Annual
ETF
Attachments To Be Submitted With This Application
1. Voided Check
2. Driver License
File Upload
Choose File
Agent
Is this application being submitted by an Agent?
Yes
No
Agent Name
Submit
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