Merchant Processing Application

* Legal Name of Business

*Age of Business

Years

Months

* Doing-Business-As

* Federal EIN or SSN
* Business Address

* Street Address

Street Address Line 2

* City

* State / Province

* Postal Code

* Country
* Business Phone Number

( ) * Area Code

* Phone Number
*Business E-mail
* Type of Organization

Sole Proprietorship Partnership Private Corp. LLC Public Corp. Non-Profit Corp. Other
* Combined Estimated Monthly Volume (MC/Visa/Discover)
* Est. Monthly Volume (AMEX)
* Highest Monthly Membership Cost
Business URL
* Number of Employees
Owner-1 Information
*Owner 1 Legal Name

* Legal First Name

* Legal Last Name
* Ownership Percentage
* Date Business Acquired
* Mobile Number

( ) * Area Code

* Phone Number
* Date of Birth
* SSN
* Drivers License Number
* DL Expiration Date
*Owner 1 Home Address

* Street Address

Street Address Line 2

* City

* State / Province

* Postal Code

* Country
Only fill out Owner-2 information if there is a business co-owner.
*Owner 2 Legal Name

* Legal First Name

* Legal Last Name
* Ownership Percentage
(100% minus Owner-1 percentage)
* Date Business Acquired
* Mobile Number

( ) * Area Code

* Phone Number
* Date of Birth
* SSN
* Drivers License Number
* DL Expiration Date
*Owner 2 Home Address

* Street Address

Street Address Line 2

* City

* State / Province

* Postal Code

* Country
Checking Account you would like your deposits to go into.
* Bank Name
* Routing Number
* Account Number
* Account Number Again
* Will you be accepting EFT/ACH (Electronic Check) from members?

Yes No
Should be Empty:

Owner-1 Information