Contact Information
First Name:
*
Last Name:
*
Phone:
*
Email:
*
Best way to contact:
Phone
Email
Organization Information
Organization (Legal Name):
*
Owner/Authorized Contact:
Website Address:
Country:
Select one:
USA
Canada
UK
Australia
NewZealand
Other
Full Street Address:
*
City:
*
State:
Select One
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Province:
Select One
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
Zip/Postal Code:
*
Phone:
*
Site/DBA Name
Check if same as above
Site/DBA Name:
(Why?)
Name your clients recognize you by
Full Street Address:
City:
State:
Select One
";
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Province:
Select One
";
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
Zip/Postal Code:
*
Phone:
*
Business Type
Tax Exempt
Sole Proprietorship
Partnership/LLC
Corporation
Federal Tax ID/GST#:
(Don't Have One?)
Sole Proprietorships Should Enter Social Security Number
Years Business Owned:
Merchant Account
Currently Accepting Credit Cards:
Yes
No
(Check all that apply) Processing Method:
Online
Pre-Authorized Recurring
Card Present/Swipe
Phone
Projected Processing Date:
Annual Visa/MasterCard/Discover Sales:
Select One:
<$49,999
$50k-$99,999
$100k-$249,999
$500k-$999,999
$1 million+
Avg Transaction Size (Estimate):
Select One:
<$99
$100-$299
$300-$499
$500-$999
$1000+
Application for the following credit cards (select all that apply).
Visa/MC/Discover
American Express
(Currently Accept AMEX?:)
Please Provide AMEX Merchant ID In Comment Field Below
Please add comments or questions here:
