Application Form

Owner / Officer Information

Owner/Officer #1 - First & Last Name *

Owner/Officer #1 - Title *

Owner/Officer #1 - Email *

Owner/Officer #1 - Phone *

Owner/Officer #1 - Ownership % *

Owner/Officer #1 - Date of Birth *

Owner/Officer #1 - Home Address *

Owner/Officer #2 - First & Last Name

Owner/Officer #2 - Title

Owner/Officer #2 - Email Address

Owner/Officer #2 - Phone

Owner/Officer #2 - Ownership %

Owner/Officer #2 - Date of Birth

Owner/Officer #2 - Home Address

Processing Details

Processing Details - Average Credit Card Sale charged to customers: $

Processing Details - Average Monthly Credit Card Volume charged: $

Processing Details - Highest Credit Card Sale charged to customers: $

Describe reason for Highest Sale amount

How many times will this highest sale $ occur? Times per Year

How many times will this highest sale $ occur? Times per Month

Describe Products/Services Sold in Detail *

How do you currently accept credit cards (describe all methods)?

% of Sales (must equal 100%): Card Present:

% of Sales (must equal 100%): Keyed (Over Phone):

% of Sales (must equal 100%): eCommerce:

Refund Policy:

Document Checklist

The items listed below are needed in additional to the information in the form above to complete your merchant services account. If you have any questions, please let us know.

Voided Check or Bank Letter

Click or drag a file to this area to upload.

Must be preprinted (no starter checks)

Driver’s License for each signer of the account listed on this form.

Click or drag a file to this area to upload.

3 Months of Processing statements (only if currently processing)

Click or drag a file to this area to upload.