Free Application
To Accept Credit Cards
This is a "live" application to accept credit cards from your customers. Once you complete this form and submit it, we will immediately begin to process your application. Please complete as much information as possible, important fields are marked as - Required Information. The more information completed, the faster we can install your service. Use the [TAB] key on your keyboard to advance to the next field.

You can also submit your application by secured fax just print this form, complete it and fax it.

If you have a question about this application that requires an Instant response Please Click Here.

Information will be kept strictly confidential. Information will be held securely. This form is not sent via email. No information is held on an Internet accessible computer. Business must be located in the United States only. Must be at least 18 years old or have a cosigner that is at least 18 years old.

Business Info

Email Address Required Information:

Ownership Required Information:

Corporation Name:

Business Name Required Information:

Address Required Information:
(not a PO Box or mail drop - Banking requirement)

Suite:

City Required Information:

State Required Information:

Zip Required Information:

Mailing Address:

Suite:

City:


State:

Zip:

Business Phone Required Information:

Daytime Phone:

Fax:

Pager:

Explain The Products Or Services Sold Required Information:

Monthly Charge Volume Required Information:
(just an estimate)

Average per Ticket Charge Required Information:
(just an estimate)

Federal Tax ID:

Date Business Opened Required Information:

Sales Method

Percentage Of Sales Via Internet % Required Information:

Internet website URL Where Web Sales Will Take Place Required Information:

Percentage Of Sales Via Mail Order % Required Information:

Percentage Of Sales Via Retail % Required Information:

Ownership Info

Owner Name #1 Required Information:

Home Address Required Information:

City, State & Zip Required Information:

Home Phone Required Information:

Social Security # Required Information:

Drivers License # Required Information:

% Ownership Required Information:

Owner Name #2:

Home Address:

City, State & Zip:

Home Phone:

Social Security #:

Drivers License #:

% Ownership:

Reference Info

Business Reference #1
 (i.e.: suppliers) Required Information:

Contact:

Phone Required Information:

Business Reference #2
 (i.e.: suppliers) Required Information:

Contact:

Phone:

Business Reference #3
 (i.e.: suppliers) Required Information:

Contact:

Phone:

Banking Info

Bank Name:

Checking Account #:

Bank Phone:

Building Info

Landlord
 (If Leasing Or Renting ):

Contact:

Phone:

Equipment Info

Equipment
(If No Equipment Or Software Make The First Selection) Required Information:

Do You Want To Accept Checks?:

Do You Want To Accept ATM Cards?:

Pin Pad Ordered:
(only retail merchants can accept PIN based ATM cards)

Misc. Info

We Will Beat ANY Price By 10%. Enter In The Website URL or Company Name And Phone Number:

If you Currently Accept Credit Cards, What Is The Name Of The Company You Use And Phone Number:
 (we will not contact them)

Comments: