Pre- Application
 
 Merchant
Company Name: Doing Business As:  
 
First Name : Middle Name : Last Name :
Company Address : City : State :
If Outside USA State: Country :  
 
Phone: Cell Phone: Home Phone:
(xxx-xxx-xxxx) (xxx-xxx-xxxx) (xxx-xxx-xxxx)
Other Phone: Fax : Email :
(xxx-xxx-xxxx) (xxx-xxx-xxxx)
Website Address : Please provide password if site is under construction
or password protected:		 Business Type:
About Business: Country of incorporation: New or Established Business:
Estimated Monthly Volume: Average Ticket: Highest Ticket:
Have you ever processed credit cards before?: If you answered Yes above please indicate
your current processor:		  
Yes
No		  
Reasons for requesting this account?: How do you process or plan to process credit cards?: Are you interested in:

TMF (violation of merchant agreement or outstanding balance)
Low Credit Score (less than 500)
Capped Volume
New Business
High Chargebacks   
(Include monthly%)

Retail
Wireless
Moto
Manually Swiped
Internet
Other  
 (please specify)

ACH Check Programs