SIGNUP FOR MERCHANT ACCOUNT

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.

SIGNUP NOW AND GET APPROVED FAST FOR THE LOWEST RATES GUARANTEED

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.

SIGNUP NOW AND GET APPROVED FAST FOR THE LOWEST RATES GUARANTEED

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