NEW LOCATION OWNERSHIP CHANGE ADDITIONAL LOCATION
 
ISO AGENT NAME : REP CODE :
ISO OFFICE PHONE : ISO OFFICE CODE : ASSOC :
OFFICE USE ONLY
MERCHANT NO : 2.0
SIC CODE : FAIR ISAAC SCORE : ANALYST :
 
 • SECTION A - PLEASE COMPLETE MERCHANT'S BUSINESS INFORMATION
 
 A1 MERCHANT INFORMATION
NAME OF ACCOUNT (DOING BUSINESS AS) : EXACT LEGAL NAME :
DBA ADDRESS (IF DIFFERENT FROM LEGAL) : LEGAL ADDRESS :
CITY :
 STATE :
 ZIP :
 CITY :
 STATE :
 ZIP :
CONTACT :
 TELEPHONE NO : FAX NO :  
EMAIL ADDRESS :
 WEBSITE ADDRESS :
 FEDERAL TAX I.D. NUMBER :
TYPE OF OWNERSHIP :
   SOLE PROPREITOR   PARTNERSHIP   CORPORATION   LLC   NON-PROFIT   OTHER :
 
 A2 MERCHANT PROFILE
MERCHANDISE/SERVICE SOLD : YEARS IN BUSINESS :
LENGTTH OF CURRENT OWNERSHIP : NO OF LOCATIONS : MONTHLY VOLUME : AVERAGE TICKET AMOUNT : HIGHEST TICKET AMOUNT :
HAS MERCHANT OR ANY PRINCIPAL BEEN TERMINATED AS A VISA/MASTER CARD MERCHANT (TMF) ?  YES     NO
REASON :
HAS MERCHANT OR ANY PRINCIPAL DISCLOSED BELOW FILED BANKRUPTCY OR BEEN SUBJECT TO ANY INVOLUNTARY BANKRUPTCY ?
YES     NO
REASON :
PERCENT OF BUSINESS
CARD SWIPED :  %
MANUAL KEY WITH IMPRINT :  %
MAIL ORDER/TELEPHONE ORDER :  %
TOTAL :  %
HAS MERCHANT PREVIOUSLY ACCEPTED CREDIT CARDS ?  YES     NO    IF YES PLEASE PROVIDE COPIES OF MOST RECENT STATEMENTS
PROCESSORS :
DOES MERCHANT CONDUCT BUSINESS SEASONALLY ?
YES     NO
DOES THE BUSINESS USE ANY THIRD PARTIES IN THE PAYMENT PROCESS ?
YES     NO
IF YES, PLEASE LIST :
WHEN IS THE CARD HOLDER BILLED FOR PRODUCTS/SERVICES ?
ON ORDER     SHIPMENT
DELIVERY OF PRODUCTS :
    TIME OF SALE
    1-3 DAYS
    3-5 DAYS
    5-15 DAYS
    15 DAYS+
REFUND POLICY :
 
Each merchant certifies that the average ticket size highest ticket and sales volume indicated is accurate and acknowledges any variance to this information could result in delayed and/or withheld settlement of funds and/or termination of merchant.
 
E-COMMERCE MERCHANTS ONLY
SERVICE PROVIDER : DOES YOUR SITE HAVE A SECURE CERTIFICATE ?
YES     NO
LIST ALL APPLICABLE URL FOR YOUR WEBSITES : IF E-COMMERCE DO YOU USE A FULFILLMENT CENTER ?
YES     NO
IF YES PLEASE LIST CONTACT INFORMATION :
 
 A3 OWNERS OR OFFICERS
PRINCIPLE #1 % OF EQUITY OWNERSHIP :  
SOCIAL SECURITY NUMBER :
 DATE OF BIRTH :
 Pick a date 		TELEPHONE # :
RESIDENCE ADDRESS :
CITY : STATE : ZIP :  
PRINCIPLE #2 % OF EQUITY OWNERSHIP :  
SOCIAL SECURITY NUMBER :
 DATE OF BIRTH :
 Pick a date 		TELEPHONE # :
RESIDENCE ADDRESS :
CITY : STATE : ZIP :  
 
PROMO CODE :  *