Retail Merchant Account Application

Upon receipt of this application, your merchant account agreement will be prepared. The agreement will detail full rate information. You are under no obligation and no account will be opened until the merchant account agreement is returned along with the following:

• A copy of the U.S. Driver's License for each owner (for verifying identity only)
• A copy of your Certificate of Incorporation or business license
• The last three to six months merchant credit card processing statements from your current or most recent merchant accounts (if applicable)
• The social security number for each owner (we do not require this information, but the acquiring bank will, so this is not collected until late in the application process)

Business Information:

Business Name:

Address:

City:

State:

Zip Code:

Business Phone:

Owner Information:

Number of Owners:

Business Owner Full Name:

Title:

Percentage of Ownership:

Home Address:

Home City, State Zip

Owner E-mail Address:

Business Contact Information:

Accounting Dept Contact:

Accounting Contact Email:

Business & Product Description:

Business Description:

Product(s) Description:

Average Sale Amount:

Monthly Processing Volume (est.):

Merchant Processing History:

Does the business currently process credit cards?

- If Yes, with which provider(s)?

- If Yes, is this account still active?

Has this business ever had a merchant account canceled?

- If Yes, please explain why:

Additional notes/comments: