Merchant Services Pre-Application
Business Legal Name
DBA Name
Business Address
City
State
ZIP
Business Phone
Business Fax
Email Address
Website
Requested Service Start Date
Is this date flexible?
No
Yes
Products/Services Sold
Number of Employees
Federal Tax ID
Month/Year ID Started
Tax Filing Type
Other
LLC
Partnership
Public Corporation
Private Corporation
Sole Proprietorship
Other Tax Filing Type
Tax Exempt?
No
Yes
Total Gross Annual Sales:
Estimated Annual Credit Card Sales:
Estimated Average Credit Card Individual Sale Amount:
Estimated Highest Credit Card Individual Sale Amount:
Signor
(must be an officer or controller of a private corp., member LLC, or an individual only of a sole proprietorship)
Signor/Owner Name
Title
% Ownership in Company
Home Address
City
State
ZIP
Home Phone
Social Security Number
Date of Birth
Driver License #
DL State
DL Expires
Deposit Bank
(checking only)
Bank Name
Routing Number
Account Number
Phone
Products and Services
Please check the products and services below that you think would help grow your business.
PIN debit/contactless/EMV payment
gift card program
check guaranty sevices
mobile/wireless payment acceptance
ecommerce
TransArmor to secure payment data at point of sale
cash advance against future receivables
point of sale system
free supplies/equipment warranty program