Initial form Thank you 1234 New Merchant Application Form Cover sheet Business DBA First Name Last Name Street Address Address Line 2 City State StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code Business Phone Number Save & continue Merchant info Business DBA Legal/Corporate Name First Name Last Name Street Address Address Line 2 City State StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code Email Address DBA Phone Number DBA Fax Number (Optional) Mobile Phone Year Established Length of Current ownership Years Months Mailing address same as above Cover sheetSave & continue Principal information (Owner/Partner/Officer) Select Role Select RoleOwner/PartnerOfficerPresidentVice PresidentManaging Member Percentage of Ownership First Name Last Name Home Address Street Address Address Line 2 City State StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code SSN DOB Home Phone Other merchant information Average Sale Amount Total MONTHLY Visa/MC/Disc/UnionPay/Amex Sales Description of Product/Services Offered 0/60 max characters What percentage of your sales are... Enter values between 0-100 (Total of all three must equal 100) Card Present Card Not Present Internet Customer Service Number (Optional) Previous Processor (Optional) Merchant infoSave & continue Bank Account (Checking Accounts Only) Deposit Bank Name ABA/Routing # DDA Account # Tape ID Tape IDNext Day (extra $5 cost, must batch before 10pm EST)48 Hours Card Acceptance Pricing Category Pricing CategoryRetailMO/TO/InternetSupermarketLodgingRestaurantARU Principal info Thank youfor applying