U.S. Merchant Account

Please complete the following application with all information that applies to you for your new bank account. If you wish to order more services, you will be given that option after submitting this form.

IMPORTANT: The following application will provide us with enough information to finalize the forms for your account, therefore saving time in the underwriting process. Completing this application DOES NOT commit you to the account, and ALL information is kept confidential and stored on our secure servers for a minimal amount of time.



Merchant Information

Legal Name of Business
Type of Ownership	Select Ownership Type Sole Proprietorship Partnership Public Corporation Private Corporation Limited Liability Company Non-Profit Corporation Medical or Legal Corporation Association/Estate or Trust Tax Exempt Organization (501C) Gov. (Federal/State/Local) International Organization International Business Company Other
DBA Name (if applicable)
Federal Tax ID (if applicable)
Date of Incorporation (if applicable)
Date Business Started
Number of Locations
Number of Employees
Contact Business Title
*Contact First Name
*Contact Last Name
*Contact E-mail
*Contact E-mail Confirmed
*Telephone
Mobile Telephone
Alternative/Business Telephone
Best Time to Call
Facsimile
*Address
Address
*City
*State/Province
*Postal/Zip Code
*Country
Physical Business Address (if different from above) *U.S. address required if business/corporate address above is outside U.S.
Name
Address
Address
City
State/Province
Postal/Zip Code
Country
Telephone

Processing Information
(IMPORTANT: your answers to the following questions will NOT affect whether you get an account--they are just to help us understand what your processing needs are and what barriers, if any, we will have to cross in order to obtain an account for you).


Services Offered
(All merchant accounts require that you accept MasterCard and Visa).

Do you accept Discover for Internet business?
Yes No

If Yes, what is your Discover Merchant Number?

If No, would you like to apply for one?
*$25 setup fee will be collected by Discover.
Yes No

Do you accept American Express for Internet business?
Yes No

If Yes, what is your American Express Merchant Number?

If No, would you like to apply for one?
Yes No

Business Information

Owner Information

Banking Information
*U.S. bank account required.

3-5 Features
(Please list below, 3-5 features you would like your Merchant Account to offer)
1.
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5.