Merchant Application Form

1

BUSINESS NAME(S)

2

MERCHANT PROFILE

3

CREDIT CARD TRANSACTION PROFILE

4

PROCESSING HISTORY

5

OWNERS AND OFFICERS

6

MERCHANT SITE INSPECTION REPORT

7

SAVE YOUR FORM

BUSINESS NAME (S)

Telephone Number
Fax Number
(Nine Digits)
Telephone Number
Alternate Phone
Mail To:      

MERCHANT PROFILE

Type of Ownership
        
Type of Goods Sold
Length of Ownership
Length of Location
Year Business Established:
Web Address URL (optional)

CREDIT CARD TRANSACTION PROFILE








On Premise Sales
Off Premise Sales
Mail Order
Telephone Order
Internet
Sales Swiped Through POS terminal
Sales keyed into POS terminal

PROCESSING HISTORY

Has the business or any associated owner ever been terminated as a VISA/MasterCard/Discover/American Express merchant?
Yes    No
Do you currently accepts VISA/MasterCard/Discover/American Express? If YES, please submit 3 most current monthly statements.
Yes    No
Are there third parties/payment applications involved with your payment process?
Yes    No
Is your business PCI compliant?
Yes    No
Has your business had any ongoing or prior data compromise investigations?
Yes    No

OWNERS AND OFFICERS

Residence Telephone
Time at Residence
Own   Rent
Date of Birth
Residence Telephone
Time at Residence
Own   Rent
Date of Birth
BANK REFERENCE
Account #
Telephone Number
Contact
TRADE REFERENCE
Account #
Telephone Number
Contact
TRADE REFERENCE
Account #
Telephone Number
Contact
TRADE REFERENCE
Account #
Telephone Number
Contact

MERCHANT SITE INSPECTION REPORT(must be completed by sales representative)

Merchant Location
Shopping Center
Retail Storfront
Residence
Mobil Merchant
Office Building
Area is Zoned
Commercial
Residential
Industrial
Square Footage
0-250
251-500
501-2000
2001+
Does the inventory, merchandise, and staff appear to be consistant with the type of business?     Yes   No

The Merchant
Owns   Leases
Landlord's Name or Mortgage Holder
Telephone Number

Complete

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