Questions?
Toll-Free: (866) 927-7180 

  This merchant application is......
powered by DepositChecks.com

M E R C H A N T   A P P L I C A T I O N

       
PLEASE COMPLETE MERCHANT'S BUSINESS INFORMATION
 MERCHANT INFORMATION                            
NAME OF ACCOUNT (DOING BUSINESS AS) NAME TO APPEAR ON CARDHOLDERS BANK STATEMENT EXACT LEGAL NAME
   
DBA ADDRESS (IF DIFFERENT FROM LEGAL) LEGAL ADDRESS - NOT A POST OFFICE BOX
   
CITY STATE ZIP CITY STATE ZIP
   
CONTACT TELEPHONE NUMBER FAX NUMBER
 
E-MAIL ADDRESS FEDERAL TAX I.D. NUMBER
   
WEBSITE ADDRESS STATE TAX I.D. NUMBER
   
TYPE OF OWNERSHIP:                                                          
 MERCHANT PROFILE
MERCHANDISE/SERVICE SOLD YEARS IN BUSINESS
   
 LENGTH OWNERSHIP # OF LOCATIONS MONTHLY TRANSACTION VOLUME AVERAGE TICKET AMOUNT HIGHEST TICKET AMOUNT
PERCENT OF BUSINESS SALES
 IN-PERSON / CARD SWIPED  %
 VIRTUAL TERMINAL  %
 MAIL ORDER / TELEPHONE ORDER   %
TOTAL 100%
HAS MERCHANT OR ANY PRINCIPAL BEEN TERMINATED AS A VISA / MASTERCARD MERCHANT (TMF)?
                    REASON: 
HAS MERCHANT OR ANY PRINCIPAL DISCLOSED BELOW FILED BANKRUPTCY OR BEEN SUBJECT TO ANY INVOLUNTARY BANKRUPTCY?
                 REASON:
HAS MERCHANT PREVIOUSLY ACCEPTED CREDIT CARDS?
              PROCESSOR:
HAS MERCHANT PREVIOUSLY PROCESSED ACH OR EFT?
              PROCESSOR:
HOW MANY CHARGEBACKS IN PREVIOUS YEAR?      
WHAT WAS DOLLAR AMOUNT OF CHARGEBACKS IN PREVIOUS YEAR?      
 HOW DO YOU ADVERTISE? - CLICK ALL THAT APPLY
 DOES MERCHANT CONDUCT BUSINESS SEASONALLY?          WHEN IS THE CARDHOLDER BILLED FOR PRODUCTS & SERVICES?              
DOES THE BUSINESS USE ANY THIRD-PARTIES IN THE PAYMENT PROCESS? 
             
 DELIVERY OF SERVICE / PRODUCTS:
IF YES, PLEASE LIST:  REFUND POLICY:
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 settlements of funds and/or termination of merchant.
 INTERNET INFORMATION
LIST ALL ADDITIONAL URL'S FOR YOUR WEBSITE:

 
 
 
DO YOU USE A BACK-END FULFILLMENT CENTER?            
IF YES, PLEASE LIST CONTACT INFORMATION:
 
 OWNERS OR OFFICERS
PRINCIPAL #1 --- FIRST NAME & LAST NAME

% OF EQUITY OWNERSHIP  .

PRINCIPAL #2 --- FIRST NAME & LAST NAME

% OF EQUITY OWNERSHIP

       
SOCIAL SECURITY NUMBER                          DATE OF BIRTH

TELEPHONE NUMBER

SOCIAL SECURITY NUMBER                          DATE OF BIRTH

TELEPHONE NUMBER

                 
Driver's License Number             Issuance State

Expiration Date

Driver's License Number                Issuance State

Expiration Date

                 
EMAIL ADDRESS EMAIL ADDRESS
   
RESIDENCE ADDRESS RESIDENCE ADDRESS
   
CITY STATE ZIP CITY STATE ZIP
   
 REFERENCES
TRADE REFERENCE CONTACT
   
ACCOUNT NUMBER TELEPHONE NUMBER
   
TRADE REFERENCE CONTACT
   
ACCOUNT NUMBER TELEPHONE NUMBER
   
 REQUESTED PROCESSING TYPES 
 BANKING INFORMATION
NAME OF MERCHANT'S BANK CONTACT
   
BANK LOCAL TELEPHONE NUMBER
 
  ROUTING / ABA NUMBER
 ACCOUNT TYPE:    CHECKING              
DDA / CHECKING ACCOUNT
 
Your message:
Approval amounts and terms are based on personal and business credit and time in business.
Our specialty is providing the lowest rates and best value available with minimal documentation required.

Upon receipt of this form, one of our Senior Merchant Representatives will contact you immediately.


© 2004, Deposit Checks, Inc ALL RIGHTS RESERVED.