SIGNUP FOR MERCHANT ACCOUNT – Merchant Services Miami Credit Card Payment Processing

1. BUSINESS INFORMATION

Legal Name of Your Business*

Legal Business Address*

City*

State*

ZIP / Postal Code*

Legal Phone Number*

Legal Fax Number

DBA Name (Doing Business As)*

DBA Address*

City*

State*

Zip*

DBA Phone Number*

DBA Fax Number

Email Address for Notices*

Customer Service Phone Number*

Website Address

Length of Years Business Owned?*

Length of Years Months Owned?*

Prefered Address For

Send Statements To*

Send Charge Backs To*

Fax Number

Contact Name*

Title*

Phone*

Any Prior Bankruptcies (Business)?*

If Yes Filling Date?*

Any Prior Bankruptcies (Personal)?*

If Yes Filling Date?*

Business Type*

MOTO %*

INTERNET %*

Business to Business %*

Detailed Business Description*

2. W-9 INFORMATION (Input information as shown on your income tax return.)

Taxpayer Identification Number*

EIN Taxpayer Identification Number (Must be 9 Digits)*

Social Security Identification Number (Must be 9 Digits)*

ITIN Identification Number*

Name (as shown on your income tax return)*

Email Address*

Type of Ownership*

Date of Birth*

3. BENEFICIAL OWNER AND OFFICER INFORMATION

Enter each individual who owns 25% or more of the equity interests of the company for which the account is being opened.

how many owners own 25% or more of the company?*

Name of Owner #1*

Title*

Social Security # or Passport #*

U.S. Persons: Enter your Social Security #. Non-U.S. Person: Enter your Passport # and Country of Issuance.

Date of Birth*

Percentage of company owned (%)*

Owner 1 residential address, city, state & zip code*

Owner 1 residential phone number*

Name of Owner #2

Title

Social Security # or Passport #

U.S. Persons: Enter your Social Security #. Non-U.S. Person: Enter your Passport # and Country of Issuance.

Date of Birth

Percentage of company owned (%)

Owner 2 residential address, city, state & zip code

Owner 2 residential phone number

Name of Owner #3

Title

Social Security # or Passport #

U.S. Persons: Enter your Social Security #. Non-U.S. Person: Enter your Passport # and Country of Issuance.

Date of Birth

Percentage of company owned (%)

Owner 3 residential address, city, state & zip code

Owner 3 residential phone number

Name of Owner #4

Title

Social Security # or Passport #

U.S. Persons: Enter your Social Security #. Non-U.S. Person: Enter your Passport # and Country of Issuance.

Date of Birth

Percentage of company owned (%)

Owner 4 residential address, city, state & zip code

Owner 4 residential phone number

Name of Officer/Manager and Title

Social Security # or Passport #

U.S. Persons: Enter your Social Security #. Non-U.S. Person: Enter your Passport # and Country of Issuance.

Date of Birth

Percentage of company owned (%)

Your residential address, city, state & zip code

Your residential phone number

4. CARD PROCESSING INFORMATION

Have you ever accepted credit cards before?*

If yes, what is the processor’s name?

Number of Locations*

Do you bill your customers prior to goods being shipped?*

If Yes, how many days?*

What is your Return and Refund Policy?*

How do you Advertise?*

Other Please Explain*

Card Types Requested*

5. Enter Credit Card Processing Methods Below (Total of 4 fields must equal 100%)

Card Swiped Transactions %*

Manually Keyed (Card Present with Imprints) %*

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

eCommerce (Card Not Present) %*

Business to Business (Must be 0-100%)*

Do you use a third party fulfillment?*

If yes, provide name and address.*

What is your Average Credit & Debit Sale Transaction (Average Ticket)?*

What is your Monthly Credit & Debit Sales Volume (Do not Include Cash Sales)?*

Does annual American Express volume exceed $1,000,000?*

Would Merchant like to receive American Express marketing materials?*

Is Your Business Seasonal?*

If your business is seasonal, indicate the months that are active (example: Jan, Feb, March, April)*

1. BUSINESS INFORMATION

Prefered Address For

2. W-9 INFORMATION (Input information as shown on your income tax return.)

3. BENEFICIAL OWNER AND OFFICER INFORMATION

4. CARD PROCESSING INFORMATION

5. Enter Credit Card Processing Methods Below (Total of 4 fields must equal 100%)

6. BANKING INFORMATION

Select how you prefer to process your credit card payments below.

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