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Merchant Services
Payment Processing
Merchant Account Types
Retail Merchant Accounts
Mobile Merchant Accounts
Ecommerce Merchant Accounts
MOTO Merchant Accounts
Our Low Rate Guarantee
Save BIG with Interchange Plus
By Industry
Retail
Food & Beverage
Business To Business
Professional Services
Ecommerce
Healthcare
Legal
Salon / Gym / Spa
Equipment
Credit Card Terminals
FD-130 Terminal
Free Credit Card Terminal
Point of Sale Systems
All Clover POS Devices
Clover Mini WiFi
Clover Mini 3G & WiFi
Clover Mobile
Clover Station POS
Clover Go Swiper
Clover Flex (NEW)
Virtual Payment Gateways
Free Authorize.net Payment Gateway
Cash Advance
Internet Marketing
Search Engine Optimization
Online Video Marketing
Mobile Marketing
Social Media Management
Mobile Website Optimization
Contact
1. BUSINESS INFORMATION
Legal Name of 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
Select One
Legal Address
DBA Address
Send Charge Backs To
Select One
Legal Address
DBA Address
Fax Number
Fax Number
Contact Name
Title
Phone
Any Prior Bankruptcies (Business)?
Select One
No
Yes
If Yes Filling Date?
Any Prior Bankruptcies (Personal)?
Select One
No
Yes
If Yes Filling Date?
Business Type
Select One
Retail
Retail with Tips
Resturant
MOTO
Internet
Lodging
Supermarket
Utility
Pharmacy
Business to Business
MOTO %
INTERNET %
Business to Business %
Select One
0%
100%
99%
98%
97%
96%
95%
94%
93%
92%
91%
90%
89%
88%
87%
86%
85%
84%
83%
82%
81%
80%
79%
78%
77%
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74%
73%
72%
71%
70%
69%
68%
67%
66%
65%
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63%
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60%
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58%
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16%
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14%
13%
12%
11%
10%
9%
8%
7%
6%
5%
4%
3%
2%
1%
Detailed Business Description
2. W-9 INFORMATION (Input information as shown on your income tax return.)
Taxpayer Identification Number
Select One
EIN
Social Security Number
ITIN
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
Select One
Sole Proprietorship
LLC
Partnership
Ltd Liability Partnership
Government Entity
Trust
Professional Assoc.
Political Organization
Public Corporation
Private Corporation
Non Profit Corporation
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?
Select One
1 Owner
2 Owners
3 Owners
4 Owners
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 (%)
Select One
0%
100%
99%
98%
97%
96%
95%
94%
93%
92%
91%
90%
89%
88%
87%
86%
85%
84%
83%
82%
81%
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79%
78%
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11%
10%
9%
8%
7%
6%
5%
4%
3%
2%
1%
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 (%)
Select One
0%
100%
99%
98%
97%
96%
95%
94%
93%
92%
91%
90%
89%
88%
87%
86%
85%
84%
83%
82%
81%
80%
79%
78%
77%
76%
75%
74%
73%
72%
71%
70%
69%
68%
67%
66%
65%
64%
63%
62%
61%
60%
59%
58%
57%
56%
55%
54%
53%
52%
51%
50%
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8%
7%
6%
5%
4%
3%
2%
1%
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 (%)
Select One
0%
100%
99%
98%
97%
96%
95%
94%
93%
92%
91%
90%
89%
88%
87%
86%
85%
84%
83%
82%
81%
80%
79%
78%
77%
76%
75%
74%
73%
72%
71%
70%
69%
68%
67%
66%
65%
64%
63%
62%
61%
60%
59%
58%
57%
56%
55%
54%
53%
52%
51%
50%
49%
48%
47%
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39%
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16%
15%
14%
13%
12%
11%
10%
9%
8%
7%
6%
5%
4%
3%
2%
1%
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 (%)
Select One
0%
100%
99%
98%
97%
96%
95%
94%
93%
92%
91%
90%
89%
88%
87%
86%
85%
84%
83%
82%
81%
80%
79%
78%
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55%
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52%
51%
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27%
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23%
22%
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15%
14%
13%
12%
11%
10%
9%
8%
7%
6%
5%
4%
3%
2%
1%
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 (%)
Select One
0%
100%
99%
98%
97%
96%
95%
94%
93%
92%
91%
90%
89%
88%
87%
86%
85%
84%
83%
82%
81%
80%
79%
78%
77%
76%
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72%
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6%
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4%
3%
2%
1%
Your residential address, city, state & zip code
Your residential phone number
4. CARD PROCESSING INFORMATION
Have you ever accepted credit cards before?
Select One
No
Yes
If yes, what is the processor’s name?
Number of Locations
Do you bill your customers prior to goods being shipped?
Select One
No
Yes
If Yes, how many days?
Select One
0-2 Days
3-30 Days
31-60 Days
61-90 Days
Over 90 Days
What is your Return and Refund Policy?
How do you Advertise?
Select One
Yellow Pages
Telemarketing
Catalog
Word of mouth
Publications
Mass/Direct mail
Internet
Other
Other Please Explain
Card Types Requested
Select One
All Credit Cards
All Credit and PIN Based Debit Cards
PIN Based Debit Cards Only
5. Enter Credit Card Processing Methods Below (Total of 4 fields must equal 100%)
Card Swiped Transactions %
Select One
0%
100%
99%
98%
97%
96%
95%
94%
93%
92%
91%
90%
89%
88%
87%
86%
85%
84%
83%
82%
81%
80%
79%
78%
77%
76%
75%
74%
73%
72%
71%
70%
69%
68%
67%
66%
65%
64%
63%
62%
61%
60%
59%
58%
57%
56%
55%
54%
53%
52%
51%
50%
49%
48%
47%
46%
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44%
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42%
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40%
39%
38%
37%
36%
35%
34%
33%
32%
31%
30%
29%
28%
27%
26%
25%
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22%
21%
20%
19%
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17%
16%
15%
14%
13%
12%
11%
10%
9%
8%
7%
6%
5%
4%
3%
2%
1%
Manually Keyed (Card Present with Imprints) %
Select One
0%
100%
99%
98%
97%
96%
95%
94%
93%
92%
91%
90%
89%
88%
87%
86%
85%
84%
83%
82%
81%
80%
79%
78%
77%
76%
75%
74%
73%
72%
71%
70%
69%
68%
67%
66%
65%
64%
63%
62%
61%
60%
59%
58%
57%
56%
55%
54%
53%
52%
51%
50%
49%
48%
47%
46%
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44%
43%
42%
41%
40%
39%
38%
37%
36%
35%
34%
33%
32%
31%
30%
29%
28%
27%
26%
25%
24%
23%
22%
21%
20%
19%
18%
17%
16%
15%
14%
13%
12%
11%
10%
9%
8%
7%
6%
5%
4%
3%
2%
1%
Manually Keyed (Card Not Present and/or Mail Order/Telephone Order) %
Select One
0%
100%
99%
98%
97%
96%
95%
94%
93%
92%
91%
90%
89%
88%
87%
86%
85%
84%
83%
82%
81%
80%
79%
78%
77%
76%
75%
74%
73%
72%
71%
70%
69%
68%
67%
66%
65%
64%
63%
62%
61%
60%
59%
58%
57%
56%
55%
54%
53%
52%
51%
50%
49%
48%
47%
46%
45%
44%
43%
42%
41%
40%
39%
38%
37%
36%
35%
34%
33%
32%
31%
30%
29%
28%
27%
26%
25%
24%
23%
22%
21%
20%
19%
18%
17%
16%
15%
14%
13%
12%
11%
10%
9%
8%
7%
6%
5%
4%
3%
2%
1%
eCommerce (Card Not Present) %
Select One
0%
100%
99%
98%
97%
96%
95%
94%
93%
92%
91%
90%
89%
88%
87%
86%
85%
84%
83%
82%
81%
80%
79%
78%
77%
76%
75%
74%
73%
72%
71%
70%
69%
68%
67%
66%
65%
64%
63%
62%
61%
60%
59%
58%
57%
56%
55%
54%
53%
52%
51%
50%
49%
48%
47%
46%
45%
44%
43%
42%
41%
40%
39%
38%
37%
36%
35%
34%
33%
32%
31%
30%
29%
28%
27%
26%
25%
24%
23%
22%
21%
20%
19%
18%
17%
16%
15%
14%
13%
12%
11%
10%
9%
8%
7%
6%
5%
4%
3%
2%
1%
Business to Business (Must be 0-100%)
Select One
0%
100%
99%
98%
97%
96%
95%
94%
93%
92%
91%
90%
89%
88%
87%
86%
85%
84%
83%
82%
81%
80%
79%
78%
77%
76%
75%
74%
73%
72%
71%
70%
69%
68%
67%
66%
65%
64%
63%
62%
61%
60%
59%
58%
57%
56%
55%
54%
53%
52%
51%
50%
49%
48%
47%
46%
45%
44%
43%
42%
41%
40%
39%
38%
37%
36%
35%
34%
33%
32%
31%
30%
29%
28%
27%
26%
25%
24%
23%
22%
21%
20%
19%
18%
17%
16%
15%
14%
13%
12%
11%
10%
9%
8%
7%
6%
5%
4%
3%
2%
1%
Do you use a third party fulfillment?
No
Yes
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?
Select One
Yes
No
Would Merchant like to receive American Express marketing materials?
Select One
No
Yes
Is Your Business Seasonal?
Select One
No
Yes
If your business is seasonal, indicate the months that are active (example: Jan, Feb, March, April)
6. BANKING INFORMATION
Name of Your Bank
Bank Routing Number
Bank Account Number
Type of Account
Checking
Savings
General Ledger
How did you hear about us?
Google
Yahoo/Bing
Youtube
Facebook
Instagram
Linkedin`
Pinterest
Craigslist
Amazon
Ebay
Press Article
Expo Event
Networking Event
Referred by Affiliate Partner
Referred by Friend or Family
Referred by Business Owner
Referred by Sales Agent
Other
Explain
Enter name of the person/business or website that referred you. (If applicable)
UPLOAD THE FOLLOWING ATTACHMENTS:
Copy of your Drivers License - (Required )
Copy of Voided Company Check - (Required)
Copy of your Company business Card,Brochure,or any other marketing material (Optional)
Copy of your “Merchant Processing Statement” for the last month — (Only required if you have a current processor)
File
Drop files here or
Select how you prefer to process your credit card payments below.
If you are not sure, do not worry, just select the last option (Black Box) and we will help.
Merchant Card Processing Agreement
SIGNUP NOW AND GET APPROVED FAST FOR THE LOWEST RATES GUARANTEED
Merchant Services
Payment Processing
Merchant Account Types
Retail Merchant Accounts
Mobile Merchant Accounts
Ecommerce Merchant Accounts
MOTO Merchant Accounts
Our Low Rate Guarantee
Save BIG with Interchange Plus
By Industry
Retail
Food & Beverage
Business To Business
Professional Services
Ecommerce
Healthcare
Legal
Salon / Gym / Spa
Equipment
Credit Card Terminals
FD-130 Terminal
Free Credit Card Terminal
Point of Sale Systems
All Clover POS Devices
Clover Mini WiFi
Clover Mini 3G & WiFi
Clover Mobile
Clover Station POS
Clover Go Swiper
Clover Flex (NEW)
Virtual Payment Gateways
Free Authorize.net Payment Gateway
Cash Advance
Internet Marketing
Search Engine Optimization
Online Video Marketing
Mobile Marketing
Social Media Management
Mobile Website Optimization
Contact
Refer a Merchant
Become a Sales Agent
Paymentix University
Blog
Social Feed
LOGIN
844-825-3729
Get Rate Quote
SAVINGS CALCULATOR
Login
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