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5 Minute Online Application
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Business Information
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Business Legal Name:
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Doing Business As:
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Owner/Officer/Principal Name:
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Contact Name (if different than above):
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Street Address:
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City:
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State:
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Zip Code:
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Phone#:
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Fax#:
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E-mail address:
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Website:
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www.
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Merchant Profile
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Type of Ownership:
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Sole Proprietor
Partnership
Corporation
Government (Federal/State/Local)
Non-Profit Organization
Other
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Merchant Type:
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Retail
Restaurant/Food
Lodging/Hospitality
Fuel
Supermarket
Internet/Website/eCommerce
Home Based Business
Other
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Types of Goods or Service Sold:
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Number of years in business:
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Percent of Credit Cards that will be Swiped (card-present transactions):
Percent of Credit Cards that will be Keyed (card-not-present transactions):
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%
%
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Has this business or any associated principal been terminated as a Visa/MasterCard merchant?
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Yes
No
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Does the business currently accept electronic payments?
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Yes
No
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What other services are you interested in (along with accepting Visa/MasterCard/Discover cards)?
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Amercian Express:
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JCB:
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Electronic Check Processing:
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Bill Pay/Internet Payment Site:
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Gift Cards/Loyalty Program:
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Merchant Cash Advance:
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Web Development:
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Other Information
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Additional comments:
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How did you find our web site or hear about us?
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