Merchant Application

Legal Name of Business (as shown on tax return)*
DBA (Doing Business As Name)*
Contact Name*
First Last
Email*
Phone*
How do you Accept Credit Cards*
- Select All
- Retail (in person)
- Mail/Telephone Order
- Website/eCommerce

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Owner Information
Owner #1*
First Last
Ownership %*
Best Phone Number*
Date of Birth*
MM slash DD slash YYYY
Social Security #*
Owner Email*
Address*
Street Address Address Line 2 City State ZIP Code
Do You Own Or Rent?*
Years at Current Address*
Please enter a number from .1 to 75.
Drivers License #*
State Issued*
Expiration Date*
MM slash DD slash YYYY
Estimate Your Credit Score*
Have you ever declared Bankruptcy?*
Hidden
Owner #2
Owner #2*
First Last
Ownership %*
Best Phone Number*
Date of Birth*
MM slash DD slash YYYY
Social Security #*
Owner Email*
Address*
Street Address Address Line 2 City State ZIP Code
Do You Own Or Rent?*
Years at Current Address*
Please enter a number from .1 to 75.
Drivers License #*
State Issued*
Expiration Date*
MM slash DD slash YYYY
Estimate Your Credit Score*
Have you ever declared Bankruptcy?*
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Bank Routing Number*
Account Number*
Monthly Volume (Visa / Mastercard)*
Please enter a number from 0 to 10000000.
Monthly Volume (AMEX)*
Please enter a number from 0 to 10000000.
Typical Ticket / Average Sales Amount*
Please enter a number from 0 to 10000000.
Highest Ticket*
Please enter a number from 0 to 10000000.

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Marketing Method - Select All That Apply*
- Select All
- Newspaper/ Magazine
- Television/Radio
- Yellow Pages
- Direct Mail
- Internet
- Outbound Telemarketing
- Social Media
- Trade Shows
Have you ever processed credit cards for the business?*
Processor Name*
Have you previously been denied approval or had your merchant account closed? (Explain)*

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How many days untill the customer recieves the product or service from when the credit card is actually charged?*
Please explain in detail the products/services you are selling and who you are selling them to:Please explain in detail the products/services you are selling and who you are selling them to:*
Please explain the product life cycle. (for example, are you fulfilling orders on behalf of yourself or any other company and shipping or having them drop shipped directly to you customer or their customer):*
Do you have a direct contract or sales order for the product/service you are providing to the end use customer? If so, can you please attach a copy of the sales order/contract for review.*
Please provide a clear copy of your cancellation/refund policy:*
Do You Ship Products?*
Please explain any shipping policies:*
Last 3 consecutive months bank statements*
Max. file size: 512 MB.
Last 6 consecutive months credit card processing statements
Max. file size: 512 MB.
Color Copy of a valid Driver's License or Passport*
Max. file size: 512 MB.
Full copy of your Articles of Incorporation (this needs to include the page that shows all owners and their ownership percentage
Max. file size: 512 MB.
Voided Check or Bank Verification Letter (Bank VL needs to be on bank letterhead and signed by a bank officer. Should show full business name, address, full routing and account numbers).*
Max. file size: 512 MB.
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IP Address
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Submit Date
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URL Referer
Name
This field is for validation purposes and should be left unchanged.

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Merchant Processing Application

Step 1 of 6

Owner Information

Owner #2

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