Please enable JavaScript in your browser to complete this form.
Legal Name of Business
DBA
EIN/Tax ID
Business Start Date
State Filed
Street (Location) Address
Mailing (Legal) Address
Business/Contact Telephone
Business/Contact email *
Business Fax #
Customer Service Telephone
Customer Service email *
Website/URL*: http
Authorized Contact First/Last Name
Equipment/Gateway: VX 520 Terminal, Authorize.net Gateway, NMI Gateway, etc
Shopping Cart (if applicable)
(If using Shopify, please request Authorize.net Gateway)
PRINCIPAL INFORMATION
Ownership % (Include all w/25%+ equity)
Title Owner, CEO, President, etc
Home Telephone
Date of Birth
Social Security Number
Driver License Number
Exp Date
State
Home Address
Personal Email Address *
SETTLEMENT ACCOUNT INFORMATION
Contact Name
Bank Routing Number
Bank Account Number
LIST TYPE OF BUSINESS/PRODUCTS/SERVICES SOLD
PROCESSING VOLUME
Estimated Monthly Volume (Visa/MC)
Estimated Monthly Volume (American Express)
Average Ticket
Highest Ticket
Face-to-face (Retail/storefront, cardholder is Present)
*Telephone/Mail/Email (MOTO, cardholder is Not Present)*
*Internet (eCommerce, online Shopping Cart)*
RETURN POLICY / HISTORY
If Other*, please explain
If Yes, please provide 3-most recent Processing Statements
*Name of any current &/or previous Processors:
If Yes*, please explain
If Yes*, please explain
B2B
B2C
If yes, please specify
CARD NOT-PRESENT & ECOMM/ONLINE MERCHANTS
List the name(s) of Fulfillment house, if any
List the name(s) of Shopping Carts and/or CRM provider(s), if any
List the name(s) of Call Center providers, if any
Business Description
Length of Operations
If you sell products, where are they stored?
List the name(s) of Chargeback Management Systems, if any
No *If Yes, what’s the deposit %?
In what geographic areas will the product(s) be marketed & sold?
What % of sales transactions are international cards?
Own ever you
What is your Warranty / Guarantee?
