Full Legal Name Of Business (corporate name as it appears on your "articles of incorporation" or Ficticious name permit) .
DBA (doing business as) if other than Legal name.
Complete Street Address of Business (the actual location) include county name.
Complete Mailing Address of Business (If you want your merchant account correspondences going somewhere else)
Phone Numbers: Business. Fax Home
Check Only One :
Sole Proprietor Partnership Corporation Non-Profit Do you currently accept Credit Cards? Yes No Type of product/service sold: (be very specific)
Marketing Method [must total 100%]:Card Swiped % Keyed with imprint of card Keyed without imprint of card%% Place of Sales [must total 100%] : Storefront% Off Premises (Feild) % Mail Order % Phone Order % Trade Shows % Other % If other Specify (where is your point of sale?) Average Sale $ Estimated monthly Charge card volume $ Business Hours / Days : Age of Bus . yrs mos. Date Bus. Acquired Tax ID # Occupational License: (County or City) # Business Bank Reference: Bank Name Business Account NumberBranch Phone Number and Contact person Trade References (3) :
Name of Company, Contact person, account #(if any), & phone number 1) 2) 3) Officer/Owner 1: (this person must be listed as an officer in the Corporate resolutionif incorporated) Full legal name Title Ownership % *(If less than 51% Owner/Officer 2 must be filled out below) Date of Birth Home Phone Full Home Address (yrs) Own Rent Social security #Drivers License # State Expiration Previous Address (if less than 3yrs) (yrs) Assets: Cash in Banks Notes ReceivableMortgages & Deeds of Trust OwnedReal EstateAutomobile (details/value)Personal property (details/value)Other Assets (details/value) Liabilities: Bills DueNotes Payable to BankIncome Tax PayableOther Taxes PayableMortgages or Loans on Real EstateInstallment Loans PayableOther Liabilities (detail/value) Officer/Owner 2: (this person must be listed as an officer in the Corporate resolution if incorporated) Full legal name Title Ownership %* Date of Birth Home Phone Full Home Address (yrs) Own Rent Social security #Drivers License # State Expiration Previous Address (if less than 3yrs) (yrs) Assets: Cash in Banks Notes ReceivableMortgages & Deeds of Trust OwnedReal EstateAutomobile (details/value)Personal property (details/value)Other Assets (details/value) Liabilities: Bills DueNotes Payable to BankIncome Tax PayableOther Taxes PayableMortgages or Loans on Real EstateInstallment Loans PayableOther Liabilities (detail/value) New Merchant Services (circle each desired): Visa/Mastercard American Express** DiscoverDiners ClubDebit - ATM** Check Guarantee** Have you (anyone on this application), ever had a Visa Mastercard Merchant Account? Yes No If yes, explain how the account closed. Existing Merchant Services (fill in your merchant account numbers to any existing service) American ExpressDiscover Diners Club Desired Equipment (circle each desired): Terminal only Terminal & Printer Mail/Telephone Order Software ***Real time/online processing *If Less than 51% ownership; a 2nd officer must sign application (when it arrives), all "personal information" must also be filled in for Officer #2 above. Combined ownership must equal 51% or more. If necessary in reaching a combined 51%+, a third officer can be included on a separate sheet. Just be sure to include all of his/her "personal information." * * American Express, Check Guarantee & Debit Card services are not available to Mail Order/Telephone Order Merchants. ***Available in DOS, Windows or Windows '95. Requirements: 386 or better and a compatable modem (Bell 212)
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