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Corporate & Merchant Services
LEADING BANKCARD ORGANIZATION * MERCHANT TRANSACTION PROCESSING SERVICES
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Merchant Application
form jpeg

Please read carefully, and enter as much information as possible when filling out the application below.

 

Business Information

 
Legal Business Name:
Federal Tax ID No:
D.B.A.:
Business Type:
Years in Business:
    
Location Address:
City:
State:
Zip:
Business Phone:
 - -
Email Address:
Web Site:
    

 

Banking Information

 
Bank Name:
Bank Phone Number:
 - -
Bank Routing Number:
(First set of numbers on bottom of check)
Bank Contact:
Bank Account Number:
Type of Account:

 

Owner/Officer Information

 
Owner/Officer Name:
First Name:
Last Name:
Owner/Officer Title:

If Other, Please Specify:

Percent of Ownership:
 %
Home Address:
City:
State:
Zip:
Residence:
Years at Current Address:
Home Phone Number:
 - -
Date of Birth: Yr:
Social Security Number:
 - -  
Drivers License Number:
Drivers License State:

License Expiration Date:
Please rate your credit:
  

Personal References (Some not living with you)

1)First Name:

Last Name:

Reference's Phone Number:
- -

Reference's Address:
City:
 State:
Zip:
  
2)First Name:
 		Last Name:
 		Reference's Phone Number:
- - 		Reference's Address:
City:

State:

 Zip:
  
3)First Name:
 		Last Name:
 		Reference's Phone Number:
- - 		Reference's Address:
City:
 State:
 Zip:
  

Credit Information:
In what categories do you expect your sales to fall? (Must = 100%)
Retail %
 Mail Order % Trade Show % Service % Internet % Other %
Average Ticket Size: $ .00
Do you currently accept credit cards?
Expected Monthly Credit Volume:
Has any of the Owner's/Officer's of this organization ever had a Bank Card relationship terminated?
Questions or Comments: