Pre-Application

This is not a guarantee of a merchant account. Once submitted, your application will be evaluated. If eligible, we will contact you. Currently, we are only able to process payments within the United States and its territories.

Submitting false information is a crime. If you submit incorrect information, we are responsible to report.

* Required

Business Information

DBA Business Name*

DBA Business Address*

City*

State*

Zip Code*

Other Business Information

Business Phone*

Email Address*

Products or Services Sold*

How long have you been in business?*

Tax ID Number*

Business Website

Owners or Officers Information

Full Name*

Title

Ownership Percentage*

Home Address*

City*

State*

Zip Code*

Cell Phone Number*

Date of Birth*

Social Security Number*

Business Profile

Type of Ownership*:

For LLC, please check if:

Swipe Percentage*

MOTO/Key In Percentage*

E-Commerce Percentage*

Visa/MasterCard/Discover Monthly Volume*

AMEX Monthly Volume*

Average Sale*

High Sale*

If you don't process AMEX transactions, please enter 0 for your AMEX Monthly Volume.

Equipment Setup

This section is not required.

Merchant Program:

How many terminals?

Terminal/POS Model?

Pin Pad:

Terminal Connection:

Auto Batch:

Time

Tip Line:

Monthly Service Fee in Dollars

Additional Equipment Info

Notes

Example, Different Mailing address, Additional Owner info

Please enter today's date.*