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Merchant Information
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Type of Entity (check one)
Corporation
limited liability company
partnership
limited partnership
limited liability partnership
sole proprietorship
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Merchants Legal Name
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D/B/A
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Federal ID (or SS# for Sole Proprietorship)
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Physical address
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City, State Zip
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State Tax ID#
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Mailing address / Billing Address
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City, State Zip
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Use of Proceeds
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State of Incorporation/Organization
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Specific Type of Business
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Date business started (mm/yy)
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length of Ownership
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E-mail Address
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Contact Name
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Position
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Phone
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Fax
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Website
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Describle Specific Type of Product/Service Sold
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Principal No. 1 Percentage (%
) of Ownership
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Name
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Social Security Number
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Date of Birth
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Position
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Driver's License # & State
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Home Phone#
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Cell Phone#
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Residence Address
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City, State Zip
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Length at Current Residence
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Prior Address, City, State Zip, if at Current Address less than 2 Years
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Principal No. 2 Percentage (%
) of Ownership
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Name
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Social Security Number
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Date of Birth
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Position
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Driver's License # & State
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Home Phone#
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Cell Phone#
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Residence Address
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City, State Zip
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Length at Current Residence
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Prior Address, City, State Zip, if at Current Address less than 2 Years
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Credit Card/Terminal Information
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Visa/MasterCard:
Card Swipe %
Manually Keyed %
Phone/Mail Order %
Internet %
Total (100%)
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Average Ticket
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Total Gross Monthly Volume
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Visa/MC Monthly Vol
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Annual Visa/MC Sales
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# of Terminals
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Check Card Program Y/N
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Discover Y/N
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Existing Account #
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Terminal Make & Model
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Gift Card Program Y/N
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American Express Y/N
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Existing Account #
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Printer Make & Model
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Debit Y/N
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Diners Club/Carte Blanche Y/N
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Existing Account #
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Software Type/POS System - Contact Name & Phone
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Pin Pad Type
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JCB Y/N
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Existing Account #
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MM/YY of CC Statements Attached (4 consecutive, complete, and within last 12 mths)
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Terminal Hardware/Software Comments
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Merchant Return Policy
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Trade References
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Company
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Contact Name
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Phone Number
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Fax
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Company
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Contact Name
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Phone Number
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Fax
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Company
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Contact Name
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Phone Number
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Fax
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Property Information
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Own Lease
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Lease Start Date
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Lease Term
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Mthly Rent/Mtg
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Type of Building
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Square Footage (approx)
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Landlord/Mortgage Company
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Phone Number
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Fax
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Contact Name
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Alternate Phone
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Landlord Email
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Bank information
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Bank Name
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Phone Number
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City
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State
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Zip
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Transit# (ABA Routing)
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Account#
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Did you enclose any additional information?
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Representative (Please Print)
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Agent#
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Contract
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