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Merchant Information Form

Please complete and submit this form. A representative will contact you shortly to complete the merchant application process

Or call us! 888-222-8032
(M - F 8 AM - 5 PM Pacific)
Your business must be located in the U.S.A.

Business Information

* Indicates required field

Legal Business Name *

Physical Address (No PO Boxes) *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Business Fax *

Type of Business (What do you sell?) *

Principal Contact Name *

First

Last

Principal Contact Email *

Principal Contact Phone *

Doing Business As (DBA) *

Mailing Address (if different) *

Line 1

Line 2

City

State

Zip Code

Country

Business Email *

Company Website *

Monthly Dollar Volume *

Average Ticket Size *

Number of Employees *

Years in Business *

Ownership Type *

Do you already own any credit card equipment? Please describe what you have. *

How do you make sales? Select all that apply. *

Owner/Principal Information

Owner/Principal Name *

First

Last

Ownership % *

Cell Phone Number *

Home Address (No PO Boxes) *

Line 1

Line 2

City

State

Zip Code

Country

Owner/Principal Title *

Owner/Principal Email *

Additional Comments: *

The information you provide on this form will be kept strictly confidential and will only be used to prepare the appropriate merchant account documents that will be sent to you for your approval via secure link.

Questions? Call Us! 888-222-8032

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