Merchant Services Application

Ownership Information

Owner First Name

Owner Last Name

Title

Email

Address

Phone

Business Information

Business Type Business TypeSole ProprietorshipLLCNPOS CorpPrivate CorpPublic Corp

Legal Business Name

DBA Name

Tax Filing Name

Business Start Date

Business Phone Number

Business Address

Business Mailing Address (if different)

Website Address

Business License Number

Business License State

Merchant Processing Information

Industry

Business Description

Average Monthly Volume

When Is the Card Charged?

Services Generally Provided

Refund Policy

Seasonal Business? Seasonal Business? Yes No

Products/Services Delivered % Out 100 Products/Services Delivered % Out 100 0-7 Days 8-14 Days 15-30 Days Over 30 Days