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
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
District Of Columbia
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
*
State / Province
*
Postal Code
United States
*
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
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
District Of Columbia
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
*
State / Province
*
Postal Code
United States
*
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
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
District Of Columbia
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
*
State / Province
*
Postal Code
United States
*
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
Submit
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