Merchant Application

To apply for our internet merchant account please fill out the form below and submit it. Someone will be in contact with you within 24 hours.

General Information
Legal Business Name:
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Doing Business As:
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Business Address:
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Business City/State/Zip:
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Business Phone:
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Business Fax:
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Date Business Started:
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Any Bankruptcies:
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Does Business Have Checking Account:
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Federal Tax ID or SSN:
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US State Business Filed In:
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Contact Name:
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Email Address:
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Website URL:
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Business Information
Type of Ownership:

Specific type of products/services sold:
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Customer Refund Policy:

Have you ever accepted Credit Cards before:
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If yes with who?

Principal 1
P1 Name:
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P1 SSN:
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P1 Percent of Ownership:
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P1 Title:
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P1 Address / No PO Box:
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P1 City/State/Zip:
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P1 Home Phone:
*

Principal 2 - Optional
P2 Name:
P2 SSN:
P2 Percent of Ownership:
P2 Title:
P2 Address / No PO Box:
P2 City/State/Zip:
P2 Home Phone:

Bank InformationTo Deposit Funds Into
Bank Name:
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Bank account #:
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Bank Transit / ABA #:
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Bank Contact:
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Account Info.
Montly Sales Volume:
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Average Ticket Price:
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Do you want Visa & MC Processing (Free Setup):

Do you want Amex Processing (Free Setup):

Do you want Discover Processing (Free Setup):

Charges: 2.1% +.25 per transaction
Charges: $10 Monthly Statement Fee
Charges: $15 Monthly Gateway Fee
Charges: $10 Monthly Minimum Fee
Do not enter anything in this field:

* indicates a required field