merchant services, merchant accounts, credit card processing, credit card equipment, check guarantee, atm machines

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	The following Express Application is not a purchase agreement. Once received, one of our representatives will contact you directly to answer any questions and complete the application process. The more information you can provide us now, the better prepared we'll be to meet your needs.

Express Application & Business Profile

(

= Required Field )

Business Entity Information

Name of Primary Contact:

Title:

Phone:

Alternate Phone:

Type:

Fax:

Email:

Your Web Address:

Legal Business Name:

DBA Name:

Business Address:

Address Line 2:

City:

State:

Zip Code:

Business Type:

Specify Other:

Business Locations:

Number of Locations:

Location Type:

State of Incorporation:

State Where Business License is Filed:

Federal Tax ID #:

Use SSN if Sole Proprietorship

Business Status:

New Business Existing
Acquired Business

Business Start Date:

Business Acquired Date:

Principal #1:

Ownership Information

Name of Principal #1:

Title:

SSN:

DOB:

% Ownership:

Home Address:

Address Line 2:

City:

State:

Zip Code:

Home Status:

Own Rent Since Date:

Credit:

How would you rate your personal credit?

Excellent Good Fair Poor

Prior Bankruptcy?

Yes No	Type:
	Year:

Principal #2:

Ownership Information

Name of Principal #2:

Title:

SSN:

DOB:

% Ownership:

Home Address:

Address Line 2:

City:

State:

Zip Code:

Home Status:

Own Rent Since Date:

Transaction Profile

Briefly Describe Your Products & Services:

Avg. Transaction Amt:

(Estimate)

Bankcard Processing Merchants Only

Bankcard Volume
Estimate: Visa/MC $:

Interval	Amount

ATM, SCRIP & POS Debit/EBT Merchants Only

Estimated Foot Traffic:

Interval	Foot Traffic

Marketing Mix:

How do you market your products/services?

(check all that apply)
Should Total 100%

	Face-to-Face Retail
	Face-to-Face Mobile Environment
	Mail/Phone Order
	Internet Sales

Products/Services
of Interest
(check all that apply)

	Retail/Restaurant Credit Card Processing
	Wireless/Mobile Credit Card Processing
	Offline Credit Card Processing for Mail/Phone/Internet Orders
	Real-time Online Credit Card Processing for Mail/Phone/Internet Orders
	ATM's, SCRIP, POS Debit/EBT for Generating Surcharge Revenue
	Check Processing
	Debit Card Processing

Lease Purchase Reprogram Existing

How Did You Hear About Us?

Comments:

Referred by:

Toll Free: 1-800-253-9679

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