Pre-Application

DBA Business Name*

DBA Business Address*

City*

State*

Zip Code*

Legal Business Name (as it appears on your tax return)*

Legal Business Address*

City*

State*

Zip Code*

Business Phone*

Email Address*

Products or Services Sold*

How long have you been in business?*

Tax ID Number*

Business Website

Full Name*

Title

Ownership Percentage*

Home Address*

City*

State*

Zip Code*

Cell Phone Number*

Date of Birth*

Social Security Number*

Swipe Percentage*

MOTO/Key In Percentage*

E-Commerce Percentage*

Visa/MasterCard/Discover Monthly Volume*

AMEX Monthly Volume*

Average Sale*

High Sale*

How many terminals?

Terminal/POS Model?

Monthly Service Fee in Dollars

Additional Equipment Info