Merchant Pre Application

Please complete the form below to submit your merchant application.

Business Legal Name *

DBA Name *

Business Address *

City *

State *

Zip*

Email *

Business Phone *

Business Fax

Requested Service Start Date *

Is this date flexible?* YesNo

Products/Services Sold *

Fed Tax ID *

Fed ID Month / Year Started *

Tax Filing Type? *

Tax Exempt Organization? * YesNo

Number of Employees? *

Total Gross Annual Sales *

Estimated Annual Credit Card Sales *

Estimated Average $$ Credit Card Individual Sale Amount: *

Estimated Highest $$ Credit Card Individual Sale Amount *

Signor (Must be officer or controller of private Corp., member LLC, or individual only of sole proprietorship):

Signor/Owner Name *

Signor Title *

Signor Percentage ownership in company *

Signor Home Address *

City *

State *

Zip*

Estimated Credit Score Range *

Deposit Bank Name (checking only):

Bank Name *

Products and Services

Upload Documents

Voided Bank Check *

If currently processing credit cards, please provide your previous month credit card processing statement.

Are you in the travel and tourism industry (e.g., a tour operator) * YesNo

Please provide the following information:

Last 3 Months of Bank Statements *

Last 3 Months of Credit Card Processing Statements *

EIN SS4 IRS Letter Document *

Secretary of State Certificate *

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