This is not a guarantee of a merchant account. Once submitted, your application will be evaluated. If eligible, we will contact you.

* Required

Business Information

DBA Business Name*

DBA Business Address*



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*


Ownership Percentage*

Home Address*



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:


Tip Line:

Monthly Service Fee in Dollars

Additional Equipment Info

Please enter today's date.*

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