Merchant Application Form

Business Name:

*

Contact Name/Title:

*

  E-mail:

*

Phone:

*

Cell Phone:

Business Address:

City:

State:

Zip:

Country:

Phone:

  Fax:

Website:

Are you a startup:

YesNo

Age of business:

Products/Services Sold:

Current Monthly
Volume: $

Projected Monthly Volume: $

Average Credit Card Transaction: $

Highest Credit Card Transaction: $

Have you ever been terminated

by
a processor before?

If YES, please explain in

comments box below.

YesNo

How is the signers personal credit?

Select OneBadFairGoodExcellent

Credit Score:

Comments: