Application
Please fill out the information below, a merchant specialist will contact you shortly if additional information is needed to process your application.
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Credit Card |
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Debit Card |
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Check Services |
If you
are interested in processing credit cards, please indicate which ones
you would like to accept:
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Visa/Mastercard |
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American Express |
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Discover |
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Carte Blanche |
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JCB |
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Bankcard Estimates: |
Average Ticket Amount $: |
Est. Monthly Credit Card Volume $: |
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Processing Method (Sum of Processing Method must equal 100%): |
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Card Swipe % |
Manually Keyed % |
Phone/Mail Order % |
Internet % |
About
Your Business:
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Legal Business Name |
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Street Address |
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City, State, Zip |
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Business Phone |
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Business Fax |
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How
Long Have You |
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Years |
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What industry are you in? |
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Type of Ownership:
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URL of the Business (if applicable) http:// |
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Have you ever had a merchant account before? YES NO |
Princpal Information:
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Percentage of Ownership |
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% |
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First Name, Last Name |
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Residence Address |
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City, State, Zip |
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Number
of years |
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Home Phone |
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Type of Processing Equipment Desired:
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Credit Card Terminal |
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Online Processing |
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Reprogramming for Existing Merchant Account |
Looking
to:
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Buy the Equipment |
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Lease the Equipment |
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Comments: |