Merchant Application

STEP 1
STEP 2
STEP 3
STEP 4
FINAL STEP

Referral Agent's DBA Name

LEGAL BUSINESS INFORMATION

Legal Entity Name

Legal Entity Address

Legal Entity Zip Code

Legal Entity City

Legal Entity State

Legal Entity Country

Legal Entity Phone

Type of Ownership

State of Formation

Fed Tax ID Type

FEIN or Social Security Number

Year Business Established

Years in Business

Years Business Owned by the Current Owner

Any Prior Bankruptcy

Type of Bankruptcy

Bankruptcy Date

PRIMARY CONTACT INFORMATION

Contact Full Name

Contact Email

Contact Phone

Contact Mobile

BUSINESS CONTACT INFORMATION

Copy From Primary

Business Contact Full Name

Business Contact Email

Business Contact Phone

Business Contact Mobile

Customer Service Phone

Does your business have a website

Primary Website Address

TECHNICAL CONTACT INFORMATION

Copy From Primary

Technical Contact Full Name

Technical Contact Email

Technical Contact Phone

FUNDS SETTLEMENT BANK INFORMATION

Bank Name

Bank Contact Name

Bank Phone

ABA Rounting Number

Bank Account/DDA Number

Industry Type

If not listed above, please fill in the industry type here

GOODS & SERVICES

Type of Goods/Services

Describe the Goods/Services Provided

Percentage Provided by Internet

Percentage Provided by Mail Order

Percentage Provided by Phone

Goods/Services Delivery Period

If Other, please describe further

Average Days for Delivery

Bought goods from a vendor

Vendor Address

Refund Policy

If Other, please describe further

Do you charge a Restocking Fee?

Is a deposit required on any sales?

Deposit Percentage

MARKETING METHODS

If Other Marketing please describe further

Do you use product Fullfillment Services?

Yes No

Do you have any processing history?

Yes No

PRODUCT FULFILLMENT

Fullfillment Method

If you chose Other above please describe further

Fulfillment Vendor Name

Fullfillment Vendor Address

Fullfillment Vendor Zip

Fullfillment Vendor City

Fullfillment Vendor State

Fulfillment Vendor Phone

Fulfillment Vendor Contact

Do you use a shopping cart

Shopping Cart Name

PROCESSING SUMMARY & HISTORY

Annual Processing Volume

Max Monthly Processing Volume

Average Monthly Processing Volume

Max Ticket Size

Average Ticket Size

Do you accept bank cards now

What percentage of your transactions are international cards

Have you ever had a merchant account terminated

If yes please explain

Who is your current processor

If you no longer use a processor what is your reason for leaving

Current Gateway Vendor Name

Which email would you like the charge back notifications sent to

Do you process seasonal sales

Peak months for seasonal sales

Peak dollar volume for seasonal sales

Do you process recurring transactions

If Other please explain further

Percentage of Monthly Recurring Transactions

Percentage of Annual Recurring Transactions

Percentage of One Time Transactions

Percentage of Other Frequency Transactions

PCI-DDS COMPLIANCE

Do you store credit card data

Any data breaches?

Are you PCI compliant?

If no, please explain.

PCI Compliance Date

How do you secure your data?

Do you use a website host provider?

Who is your host provider?

PRINCIPAL #1 INFORMATION

Principal First Name

Principal Last Name

Principal Title

Principal Percentage of Ownership

Principal Home Address

Principal Zip Code

Principal City

Principal State

Does the Principal own or rent a home?

Years Principal lived at current home?

Principal Home Phone

Principal Mobile Phone

Principal Email

Principal Country of Citizenship

Principal Social Security Number

Principal Date of Birth

Government Issued ID Type

Government Issued ID Number

Government Issued ID State

Governement Issued ID Expiration Date

Name of Relative not living with you

Phone Number of Relative Not Living with you

Add Another Principal Information

LEGAL BUSINESS INFORMATION

Principal #2 First Name

Principal #2 Last Name

Principal #2 Title

Principal #2 Percentage of Ownership

Principal #2 Home Address

Principal #2 Zip Code

Principal #2 City

Principal #2 State

Does Principal #2 own or rent a home?

Years Principal #2 lived at current home?

Principal #2 Home Phone

Principal #2 Mobile Phone

Principal #2 Email

Principal #2 Country of Citizenship

Principal #2 Social Security Number

Principal #2 Date of Birth

Principal #2 Government Issued ID Type

Principal #2 Government Issued ID Number

Principal #2 Government Issued ID State

Principal #2 Government Issued ID Expiration

Name of Relative not living with you

Phone Number of Relative Not Living with you

BUSINESS LOCATION INFORMATION

Type of Zoning for your business

Type of Premises

If Other, please describe further

Square Footage of the Location

Premises Ownership

If Other, please describe further

Multiple Business Locations

Number of Locations

PLEASE UPLOAD FOLLOWING DOCUMENTS

Certificate of Incorporation

Choose a file

Max. size: 256.0 MB

Tax ID document/ SS4

Choose a file

Max. size: 256.0 MB

Owner's driver's license

Choose a file

Max. size: 256.0 MB

Void check for each of the bank accounts where deposits can be made (please do include the month and year when the account was opened)

Choose a file

Max. size: 256.0 MB

Merchant Application

STEP 1

STEP 2

STEP 3

STEP 4

FINAL STEP

Referral Agent's DBA Name

Referral Agent's DBA Name

LEGAL BUSINESS INFORMATION

Legal Entity Name

Legal Entity Address

Legal Entity Zip Code

Legal Entity City

Legal Entity State

Legal Entity Country

Legal Entity Phone

Type of Ownership

State of Formation

Fed Tax ID Type

FEIN or Social Security Number

Year Business Established

Years in Business

Years Business Owned by the Current Owner

Any Prior Bankruptcy

Type of Bankruptcy

Bankruptcy Date

PRIMARY CONTACT INFORMATION

Contact Full Name

Contact Email

Contact Phone

Contact Mobile

BUSINESS CONTACT INFORMATION

Business Contact Full Name

Business Contact Email

Business Contact Phone

Business Contact Mobile

Customer Service Phone

Does your business have a website

Primary Website Address

TECHNICAL CONTACT INFORMATION

Technical Contact Full Name

Technical Contact Email

Technical Contact Phone

FUNDS SETTLEMENT BANK INFORMATION

Bank Name

Bank Contact Name

Bank Phone

ABA Rounting Number

Bank Account/DDA Number

Industry Type

If not listed above, please fill in the industry type here

GOODS & SERVICES

Type of Goods/Services

Describe the Goods/Services Provided

Percentage Provided by Internet

Percentage Provided by Mail Order

Percentage Provided by Phone

Goods/Services Delivery Period

If Other, please describe further

Average Days for Delivery

Bought goods from a vendor

Vendor Address

Refund Policy

If Other, please describe further

Do you charge a Restocking Fee?

Is a deposit required on any sales?

Deposit Percentage

MARKETING METHODS

If Other Marketing please describe further

Do you use product Fullfillment Services?

Do you have any processing history?

PRODUCT FULFILLMENT

Fullfillment Method

If you chose Other above please describe further

Fulfillment Vendor Name

Fullfillment Vendor Address

Fullfillment Vendor Zip

Fullfillment Vendor City

Fullfillment Vendor State

Fulfillment Vendor Phone