Merchant Application

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Merchant Pre-Application

Please fill out the fields below.

Business Legal Name *

DBA Name *

Business Address *

Business Phone *

Business Fax:

Business Website URL *

Business Email

Contact Name

Phone

Contact Email

Type Of Entity *

Fed Tax ID *

Month/ Year Started *

Number Of Employees *

Product/ Services Sold *

Hours of Operation *

Total Gross Annual Sales *

Annual Credit/Debit Card Sales *

Average ($) Credit/Debit Card Individual Sales Amount *

Estimated Highest ($) Credit/Debit Card Individual Sales Amount *

What percent is Credit/Debit Card *

What percent is Web based / Gateway *

What percent is Mail / Phone Order *

Number of Inside Processing Terminals *

Number of Outside Processing Terminals *

Signer/ Owners Name *

Signer Title *

Signer Percent of Ownership *

Signer Social Security Number *

Signer Date of Birth *

Signer Home Phone *

Signer Home Address *

Deposit Bank Name *

Bank Routing Number *

Bank Checking Account Number *

Bank Phone Number *

Due Diligence Documentation: * Voided check or Bank Letters Driver License or Passport (for Each Signer/Principal Business License or Articles of incorporation/ Organization or Operating Agreement

Documentation

POS System *

Payment Terminal/ PIN Pad * Ingenico Lane 3000 Ingenico Lane 5000 Reveal Ingenico Move 5000 Ingenico iSelf Series Ingenico iUC285 Online Gateway Integration

Sales Office *

Rep Name *

Rep Email *

Rep Phone *

Comments *