Merchant Services Application and AgreementMerchant Services Application and Agreement • April 8th, 2011 • Texas
BUSINESS FORMATION DOCUMENTS (DBA, ARTICLES OF INCORPORATION, ETC) THE FOLLOWING ADDITIONAL DOCUMENTATION MAY BE REQUIRED:
Merchant Services Application and AgreementMerchant Services Application and Agreement • July 28th, 2006
MERCHANT INFORMATION DBA NAME/OUTLET NAME: LEGAL NAME (IF DIFFERENT THAN DBA): PHYSICAL STREET ADDRESS (NO P.O. BOX): LEGAL ADDRESS: CITY, STATE, ZIP: CITY, STATE, ZIP: DBA PHONE: FAX: CORP. PHONE: FAX: CONTACT NAME AT THIS ADDRESS: E-MAIL: CONTACT NAME AT THIS ADDRESS: E-MAIL: CUSTOMER SERVICE PHONE # (REQUIRED FOR ALL MERCHANTS): WEB SITE ADDRESS (REQUIRED FOR INTERNET MERCHANTS):
Merchant Services Application and AgreementMerchant Services Application and Agreement • April 8th, 2011 • Texas
Products Requested (Check All That Apply) Virtual Terminal Transporter Secure Webpay Soft Terminal✔ Direct Interface / API Direct Billing Other – Specify Estimated Monthly ACH / e-Check and Credit Card Volume Will You Be Using ACH To Collect Funds? Yes No If Yes, Complete Below. Will You Be Using Credit Cards To Collect Funds or Yes NoAccept Online Rental Apps? If Yes, Complete Below. Average Sale$ Maximum Sale$ Monthly Sales$ Average Sale$ Maximum Sale$ Monthly Sale$ Please Specify The Products / Services That You Will Be Collecting for via ACH. Please Specify The Products / Services That You Will Be Collecting for viaCredit Cards. Will You Be Using ACH To Disburse Funds?If Yes, Complete Below. Yes No Transaction TypesHow Will You Be Obtaining Authorization For Your Transactions?(Please Indicate By Filling In The Percentages.) % Face-to-face (PPD / CCD / BOC / POP) % Single % Internet Order (WEB) % Recurring % Mail Order (ARC) 100 % Total % Telephone Order (TEL) % Fax (PPD / CCD) 100
PLEASE REMIT APPLICATION TO: (OVERNIGHT DELIVERY RECOMMENDED)Merchant Services Application and Agreement • June 7th, 2010 • Texas
MERCHANT INFORMATION DBA / OUTLET NAME CORPORATE NAME (IF DIFFERENT THAN DBA): PHYSICAL STREET ADDRESS: (NO P.O. BOXES) ADDRESS: CITY STATE ZIP CITY STATE ZIP PHONE: FAX: PHONE: FAX: CUSTOMER SERVICE PHONE NUMBER (REQUIRED FOR ALL MERCHANTS) WEB SITE ADDRESS: (REQUIRED FOR INTERNET MERCHANTS)
MERCHANT SERVICES APPLICATION AND AGREEMENTMerchant Services Application and Agreement • July 12th, 2013 • Nevada
GENERAL BUSINESS INFORMATION Merchant Name (DBA or Trade Name): Corporate/Legal Name (if different): Physical/Location Address: Corporate Address (if different): City: State: Zip: City: State: Zip: Business Telephone: Business Facsimile: Website: Date Business Formed: Years in Business: Months: Start-Up/New Company Federal Tax ID (or SSN if an individual): Number of Locations: Contact Name: Contact Email: Contact Telephone: Contact Facsimile: TYPE OF BUSINESS Sole Proprietorship Corporation (Attach Articles) LLC (Attach Articles) Partnership Publicly Traded -- Stock Symbol: Government Entity (Attach Articles & Tax Determination Letter) Non-Profit (Attach Articles & Tax Determination Letter) Foreign Entity -- Describe: Domestic Registration Yes No If Yes, State: Other: Are you a Franchisee? Yes No If Yes, Franchise Name That Will Be Utilized (Please Attach Franchise Agreement): OWNERSHIP (If a Privately Held Entity - Must Meet or Exceed 51% Ownership) (If a Non-Profit, Publicly Tr
Merchant Services Application and AgreementMerchant Services Application and Agreement • December 27th, 2023
MERCHANT INFORMATION DBA / OUTLET NAME CORPORATE NAME (IF DIFFERENT THAN DBA): PHYSlcAL STREET ADDRESS: (NO P.O. BOXES) ADDRESS: CITY STATE ZIP CITY STATE ZIP PHONE: FAX: PHONE: FAX: CUSTOMER SERVICE PHONE NUMBER (REQUIRED FOR ALL MERCHANTS) WEB SITE ADDRESS: (REQUIRED FOR INTERNET MERCHANTS)
