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Please print and complete the information below and fax to the number listed below. |
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| Business Name: | How long in business: | ||
| DBA Name: | Type of business: sole-proprietorship: Partnership: | ||
| Address: | Sub S Corp or LLC Corporation | ||
| City: State: Zip: | Own or Rent | ||
| Phone: | Fax: | ||
| Do you have prior experience in this business? | How many years? | ||
| Fed Tax ID# or SS# | How long at business address? | ||
| Email address: | Website URL: Http://www. | ||
| Owner #1 Name: | SS#: | ||
| Address | City | State : | Zip: |
| Home Phone | Birth date: ____/____/______ | ||
| Driver's License Number: | State: | ||
| Owner #2 Name: | SS#: | ||
| Address: | City: | State | Zip: |
| Home Phone: | Birth date: ____/____/______ | ||
| Driver's License Number: | State: | ||
| Rate your Credit Bureau Score (1 to 10) 1 = Poor, 10 = Great: | Bankruptcy? | Discharged When? | |
| Your Bank: | Bank Phone: | Contact: | |
| Bank routing Number: | Bank Account Number: | ||
| Business Reference: | Phone: | Contact: | Account: |
| How do you sell your products? Imprint Card & Hand Key Sale _______ % Swipe Card _______% Mail/Phone_______% | |||
| Do you wish to accept: AMEX___________ at %.00 per month and 0.00% Discover ? _____________ at 2.44% plus ten cents | |||
| Describe products & services sold: | |||
| How long until customer receives product? | |||
| Do you charge customer's Card before Customer Receives Product? yes no How Long before? | |||
| Average credit card sale $ | Monthly credit card volume $ | ||
| Which merchant program are you applying for? Touch-tone Telephone Equipment Purchase AuthorizeNet PC Software | |||
| Do you have Existing Equipment or Software to reprogram? yes no | |||
| Credit Card Payment Information: (Check If Purchasing Payment Gateway) Manual Imprinter Equipment Software | |||
| Cardholder Name: Credit Card Number: Expiration Date: Card Value Code: | |||
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FAX COMPLETED FORM TO: 260-338-0995 |
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