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    Business Information

    Client's Business Name (Doing Business As) (required)

    Business Address (required)

    City (required)

    State(required)

    zip(required)

    Location Phone #(required)

    Location Fax #

    Business Email Address(required)

    Business Website Address(required)

    Customer Service Phone #(required)

    Customer Service Email Address(required)

    Corporate Information

    Client's Corporate/Legal Name (Use Also For Head quarter's information)

    Billing Address (If Different Then Location Address)

    City

    State

    zip

    Contact Name

    Contact Fax# / Email Address:

    Contact Phone #

    Send Retrieval Requests to:
    Business LocationCorp/Legal Location

    Send Merchant Monthly Statement to:
    Business LocationCorp/Legal Location

    Federal Tax ID # (as it appears on your income tax return)

    ADDITIONAL CREDIT / SITE SURVEY INFORMATION - ALL MERCHANTS

    Zone
    Business DistrictIndustrialResidential

    Location
    MallOfficeHomeShopping AreaApartmentIsolatedDoor-to-DoorFlea MarketOther

    How many employees:

    Remaining Floors Occupied by:
    ResidentialCommercialCombinationNone

    Approximate Square Footage:
    0-250251-500501-20002001 plus

    Are customers required to leave a deposit?
    YesNo

    If yes, % of deposit required:

    Return Policy:
    Full RefundExchange OnlyNone

    OWNERS / PARTNERS / OFFICERS

    Name (First, MI, Last) (required):

    % Ownership (First, MI, Last) (required):

    Title (First, MI, Last) (required):

    Home Address (required):

    City (required):

    State (required):

    Zip (required):

    Telephone (required):

    D.O.B. (required):

    SETTLEMENT INFORMATION

    Financial Data

    Deposit Bank (required):

    Transit / ABA # (required):

    Deposit Account # (required):

    TRANSACTION INFORMATION

    Gross YEARLY Sales Volume(Cash + Credit + Debit + Check) (required):

    Average YEARLY MC/Visa Volume (required):

    Average YEARLY Discover Network-PayPal Volume (required):

    Average YEARLY American Express OptBlue Volume (required):

    Avg. MC/Visa/Discover Network-PayPal Tickets (Estimate if Never Processed in the Past) (required)

    Avg. American Express OptBlue Ticket (Estimate if Never Processed in the Past) (required)

    Highest Ticket Amount (required)

    Where is sale Transacted? (The following must add up to 100%)

    Store Front/Swiped (required)

    Internet (required)

    Mail Order (required)

    Telephone Order (required)

    Signature

    Terms of Agreements

    Signature (required)

    Title (required)

    Print Name of Signer (required)

    Date (required)

    Personal Guarantee

    View Statement

    Signature (required)

    Print Name (required)

    Date (required)