Merchant test form

Merchant Application Form

Referral Agent's DBA Name:

If you are not using an agent, please leave blank.

LEGAL BUSINESS INFORMATION

Legal Entity Name*:

Legal Entity Address*:

Legal Entity Country *:

Legal Entity Zip Code *:

Legal Entity State *:

Legal Entity City *:

If you are not using an agent, please leave blank.

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 *:

PRIMARY CONTACT INFORMATION

Business Contact Email *:

Business Contact Phone *:

Customer Service Phone *:

Does your business have a website? *:

Primary Website Address:

Website URL #2:

Website URL #3:

Website URL #4:

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 *:

All percentage provided by Internet, Mail Order & Phone must = 100%.

Percentage Provided by Mail Order *:

All percentage provided by Internet, Mail Order & Phone must = 100%.

Percentage Provided by Phone *:

All percentage provided by Internet, Mail Order & Phone must = 100%.

Goods/Services Delivery Period *:

All percentage provided by Internet, Mail Order & Phone must = 100%.

If Other, please describe further.:

Average Days for Delivery *:

Bought goods from a vendor? *:

Please put the name of the vendor here. If you do not purchase your goods from a vendor, please put "No".

Vendor Address *:

Refund Policy *:

If Other, please describe further.:

Do you charge a Restocking Fee? *:

Is a deposit required on any sales? *:

Deposit Percentage:

If you answered "yes" above, what percentage of the sales is required?

MARKETING METHODS

If "Other Marketing", please describe further:

PRODUCT FULLFILLMENT

Do you use product Fullfillment Services? *: YES NO

PROCESSING SUMMARY & HISTORY

Do you have any processing history? *:
YES NO

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 *:

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*:

Tax ID document/ SS4*:

Owner's driver's license*:

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)*:

Merchant Application Form

LEGAL BUSINESS INFORMATION

PRIMARY CONTACT INFORMATION

PRIMARY CONTACT INFORMATION

TECHNICAL CONTACT INFORMATION

FUNDS SETTLEMENT BANK INFORMATION

GOODS & SERVICES

MARKETING METHODS

PRODUCT FULLFILLMENT

PROCESSING SUMMARY & HISTORY

PCI-DDS COMPLIANCE

PRINCIPAL #1 INFORMATION

LEGAL BUSINESS INFORMATION

BUSINESS LOCATION INFORMATION

PLEASE UPLOAD FOLLOWING DOCUMENTS

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