Use this form to get started if you don't have credit card processing or would like us to quote for credit card processing services.

Do you have questions about this form? Click here for a FAQ regarding Merchant Accounts and how this process is different (and better) than a 'big tent' service like Paypal or Stripe.
Applicant Information
Applicant Name*
First Name Last Name
Applicant Email Address*
Applicant Telephone*
Additional Information
Please provide additional information about your business here.

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Business Information
Legal Name of Business*
DBA
EIN / Tax ID
We will call you for this number which is used to perform a background and credit check. While our site and form is secure, we prefer not to keep a local copy of this data which will be directly entered into the application for underwriting with the bank.
State Filed*
Business Type*
Business Start Date*
MM slash DD slash YYYY
Street Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mailing Address (if different from Street Address)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Business Telephone*
Business Email Address*
Customer Service Telephone
Customer Service Email Address
Website*

If website is not ready, please provide "dummy" login for test website.
Alternate Website
Website Notes
Please include any comments about the site and the development process. If a Username and Passsword are required to view the site, please include those here.
Authorized Contact*
First Name Last Name
Type of Terminal / Equipment

i.e., VX 520 Terminal, Authorize.net Gateway, Mobile Card-Reader
Number of Employees*
Office Location*
Approximate Square Footage*
Own or Rent?*

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Principal Information
Full Name*
First Name Middle Last Name
Title*

ex: Owner, CEO, President, etc.
Ownership Percentage*
Please include all owners with 25% or more equity. Click the "+" icon to add additional rows.
Name Percentage
Social Security Number
We will call you for this number which is used to perform a background and credit check. You will need to have this information available for all business owners. While our site and form is secure, we prefer not to keep a local copy of this data which will be directly entered into the application for underwriting with the bank.
Date of Birth*
MM slash DD slash YYYY
Driver License Number*
License State*
License Expiration Date*
MM slash DD slash YYYY
Home Telephone*
Personal Email Address*
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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Settlement Account Information
Bank Name*
Bank Telephone*
Bank Contact Name*
First Name Last Name
Bank Routing and Accounting Numbers
We will call you for this number which is used to perform a background and credit check. While our site and form is secure, we prefer not to keep a local copy of this data which will be directly entered into the application for underwriting with the bank.

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List Type of Business / Products / Services Sold
List*
Please list type of business, products and/or services sold. Click the "+" icon to add more rows.

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Processing Volume
Estimated TOTAL Monthly Volume (Cash, Checks, ACH, etc)*
Estimated % Monthly Volume (Visa)*
Please enter a number from 0 to 100.
Estimated % Monthly Volume (MC)*
Please enter a number from 0 to 100.
Estimated % Monthly Volume (Discover)*
Please enter a number from 0 to 100.
Estimated % Monthly Volume (American Express)*
Please enter a number from 0 to 100.
Estimated Monthly Volume (Other)
Please enter a number less than or equal to 100.
Average Ticket*
Highest Ticket*

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Transaction Method(s)
Please indicate the percentage of your business that is conducted via each transaction method listed below. Percentages must total 100%. Please do not include the "%" sign with your input.
Face to Face*
Retail / Storefront; Cardholder is present. Please enter percentage:
Please enter a number less than or equal to 100.
Telephone / Mail / Email*
MOTO; Cardholder is NOT present. Please enter percentage:
Please enter a number less than or equal to 100.
Internet*
eCommerce, Online Shopping Cart. Please enter percentage:
Please enter a number less than or equal to 100.

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Applicant Authorization
Electronic Signature*
First Name Middle Last Name
Please provide your full name in the fields above.
*
- Confirm signature
Email
This field is for validation purposes and should be left unchanged.

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Applicant Information

Business Information

Name	Percentage