MERCHANT INFORMATION FORM

Business Information

^*Indicates required field

Legal Business Name^*
The field is required.

Doing Business As Name (DBA)^*
The field is required.

Physical Address (No PO Boxes)^*
The field is required.
The field is required.
The field is required.
The field is required.
The field is required.

Phone Number ^* The telephone number is invalid.The field is required.
Business Fax
Business Email^* Invalid Email FormatInvalid Email FormatThe field is required.

Mailing Address (if different)

Type of Business (What do you sell?)^*
The field is required.
Company Website

Principal Contact Name^*
The field is required.
The field is required.

Principal Contact Email^*
Invalid Email FormatInvalid Email FormatThe field is required.
Principal Contact Phone^*
The telephone number is invalid.The field is required.

Ownership Type^*
---Sole ProprietorshipPrivate CorporationPublic CorporationGovernment (Federal/State/Local)PartnershipLimited Liability CompanyNonprofit CorporationAssociations, Estates, and TrustsMedical or Legal CorporationInternational OrganizationTax Exempt OrganizationThe field is required.

Monthly Dollar Volume^*
The field is required.
Average Ticket Size^*
The field is required.
Number of Employees^*
The field is required.
Date Your Business Started ^*
The field is required.

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

How do you make sales? Select all that apply.^*
In my store or restaurantOn my websiteOver the phoneI need a mobile solutionOtherThe field is required.

Owner/Principal Information

Owner/Principal Name^*
The field is required.
The field is required.
Owner/Principal Title^*
The field is required.
Owner/Principal Email^*
Invalid Email FormatInvalid Email FormatThe field is required.
Cell Phone Number^*
The telephone number is invalid.The field is required.
Ownership %^*
The field is required.

Home Address (No PO Boxes)^*
The field is required.
The field is required.
The field is required.
The field is required.
The field is required.

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.