Merchant Processing Application Agreement

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DBA:
Corporate/Legal Name:
Full Contact Name:
Physical Address:
City/State/Zip:
Mailing Address:
City/State/Zip:
Business Phone/Fax:
Email Address:
Website URL:
Referred By:
Ownership Type:	Sole Proprietorship Partnership Non-Profit Public Corporation Private
Years in Business:
Merchant Type (SIC/MCC Code):
Business License #:
Federal Tax ID:
State Tax ID:
Check One:	Retail Restaurant with Tips Restaurant without Tips MO/TO
Product/Service Description:

Average Ticket Size:
Monthly Credit Card Volume:
Mag Swipe:
Keyed Manually:

American Express Account:	New Existing -> Account #:
Discover Account:	New Existing -> Account #:
Other Card Account:
EBT:
FNS # (XREF):
Check Service:

Deposit CK Account:	Routing/Transit #: Account#:
Chargeback CK Account:	Routing/Transit #: Account#:

Owner/Officer Name:
Date of Birth:
Home Phone:
Home Address:
City/State/Zip:
Driver's License Number/State:
Social Security Number:

Owner 2/Officer 2 Name:
Date of Birth:
Home Phone:
Home Address:
City/State/Zip:
Driver's License Number/State:
Social Security Number:

Gift/Loyalty Card Program:	Yes No
Merchant Reporting:	Web-Based Paper

Building Type:	Shopping Center Office Building Residence Separate Building Other
Merchant:	Owns Rents/Leases
Area Zoned:	Commercial Industrial Residential
Square Footage:	0-500 501-2,500 2,501-5,000 5,001-10,000 Greater Than 10,001
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