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Credit Card Application

Business Info - Content

Legal Name of Business *

Address *

Legal Phone *

DBA Name and/or Address (same as legal?) *

Yes

DBA Name *

DBA Address *

DBA Phone *

Email Address *

Website Address *

Merchant Customer Service Phone *

Date Business Opened (Month and Year) *

Chargeback Notifications Email *

Chargebacks Address *

Legal

DBA

What physical USPS mailing address should chargeback letters be mailed to?

Statements Address *

Legal

DBA

What physical USPS mailing address should chargeback letters be mailed to?

Contact First & Last Name *

Contact Phone *

Position in company (owner, admin etc.) *

Any Prior Business Bankruptcies? *

Yes

Any Prior Personal Bankruptcies? *

Yes

Ownership and IRS W-9 Info - Content

Business Name (Exact business name submitted on your last income tax return) *

Name of Contact for Secure IRS Related Information *

Position in company (owner, admin etc.) for Secure IRS Related Information *

Email of Contact for Secure IRS Related Information *

Receive 1099K Statements Via Secure Email? *

Yes

Type of Ownership *

Tax Exempt *

Yes

Type of Tax ID *

EIN

SSN

ITIN

Tax Identification # (TIN) *

Business Type *

Description of Products or Services Sold *

Owner/Officer Info - Content

Name *

Job Title *

U.S. Citizen/U.S. Resident *

Yes

Social Security # *

Date of Birth *

MM/DD/YYYY

% Ownership *

Country Of Residence *

Residential Address *

Residential Phone *

Add Another Owner's Info *

Yes

Name *

Title *

U.S. Citizen/U.S. Resident *

Yes

Social Security # *

Date of Birth *

% Ownership *

Country Of Residence *

Residential Address *

Residential Phone *

Add Another Owner's Info *

Yes

Name *

Title *

U.S. Citizen/U.S. Resident *

Yes

Social Security # *

Date of Birth *

% Ownership *

Country Of Residence *

Residential Address *

Residential Phone *

Processing Info - Content

Has Merchant Ever Accepted Credit Cards Before? *

Yes

Processor Name *

Number of Locations *

Does Merchant Bill Their Customers Prior to Goods Being Shipped? *

Yes

How Many Days Prior? *

0-2

3-30

31-60

61-90

Over 90

What is your Return and Refund Policy? (Please be Specific) *

Is This a Seasonal Business? *

Yes

What type of credit card processing are we doing for you?

Card-Swiped Transactions % *

Manually Keyed (Card Present with Imprint) % *

Manually Keyed (Card Not Present and/or Mail Order/Telephone Order) % *

eCommerce (Card Not Present) *

*NOTE: Total of Above Must Equal 100%

Business to Business Sales % (Value must be 0 - 100%)* *

Does Merchant Use a Third-Party to Fulfill Products or Services? *

Yes

Projected Volume - Content

Average Transaction (Ticket) Amount $ *

Total Monthly Sales $ *

Does Annual AMEX Volume Exceed $1,000,000? *

Yes

Would Merchant Like to Receive AMEX Marketing Materials? *

Yes

Banking Info - Content

Bank Name *

Routing # *

Account # *

Type of Account *

Bank Phone # *

Add Another Bank Account *

Yes

Bank Name *

Routing # *

Account # *

Type of Account *

Bank Phone # *

Add Another Bank Account *

Yes

Bank Name *

Routing # *

Account # *

Type of Account *

Bank Phone # *

Auto-batch time *

*recommended time for next day deposit

Do you take HSA payments? *

Yes

Do you take Insurance payments? *

Yes

Upload Voided Check *

Upload Drivers License *

Upload up to 3 existing statements from your current processor (if you have them)

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