MERCHANT PROCESSING APPLICATION AND AGREEMENTProcessing Application and Agreement • September 6th, 2018
OWNER/PARTNER/OFFICER 3 OWNER/PARTNER/OFFICER 4 Name Name Title % Of Ownership* Guarantor** Yes No Title % Of Ownership* Guarantor** Yes _ No Home Addresss Home Address City State Zip City State Zip Telephone Telephone Social Security # Date of Birth Social Security # Date of Birth Email Address Email Address Prior Bankruptcie Yes No _Business and/or Personal Prior Bankruptcies Yes No Business and/or Personal Date Discharged Date Discharged
BankAssoc 1 MERCHANT PROCESSING APPLICATION AND AGREEMENT BankAssoc1Processing Application and Agreement • January 14th, 2010 • Minnesota
BPay 1206 MERCHANT PROCESSING APPLICATION AND AGREEMENT BPay1206(ia)Processing Application and Agreement • June 25th, 2009
BUSINESS NAME(S) MERCHANT PROFILE Business Name/DBA Website Location Address Email City, State, Zip Location #OF Expected Card SalesMO YR Contact Name Type of Business RETAIL MOTO E-COM Type of Goods/Service Sold Phone Number Fax Number Seasonal Sales Average Ticket Max Ticket Business Legal/Mailing Name High Volume Months Reason for Leaving Current Processor Legal/Mailing Address Current Processor *If processing must include current statements with application City, State, Zip Method of Sales Store Front % Internet %MOTO %Tradeshow % TOTAL 100% Elec Data Capt % Key Ent w/Imprint % Key Entered CNP % TOTAL 100% B2C % B2B % TOTAL 100% Contact Name Phone Number Fax Number COMPANY INFORMATION Ownership TypeSole Prop. Government Corp S,C LLC International Org Partnership Medical/Legal Corp Tax Exempt State/Country Business Filed Federal Tax ID Name of Previous Business Prior Bankruptcies?Discharge Date Yes No Business Personal Business Open Date Length of Current Ownership Trade
