MERCHANT PROCESSING PRE-APPLICATION

First Name *

Last Name *

Email Address *

Phone Number *

Tell Us About Your Business

Business Name(DBA)

Street Address

City

State/Province

ZIP / Postal Code

Location Phone # *

Customer Service Phone # *

Location Fax #

Website Address

Business Start Date Month/Year Started:

Length of Current Ownership (Months and Years)

Seasonal Merchant? *YesNo

Return Policy

Product & Services Sold *

Billing Address

Corp/Legal Name(if different than DBA) *

Corporate Street Address

City

State/Province

ZIP / Postal Code

Country

Contact Name *

Contact Phone # *

Business Email Address *

Tax Type:

Federal Tax ID#: (as it appears on your income tax return) *

Tax Filing Name (as it appears on your income tax return) *

Corporation/Type of Ownership

State Incorporated

Send Retrieval/Chargeback Requests to *

Business Type

I certify that I am a foreign entity/nonresident alien. (If checked, please attach IRS Form W-8.)Yes

Provide Owner Information

Provide the following information for each individual who owns, directly or indirectly, 25% or more of the equity interest of your business.

How many owners have 25% or more ownership in your company? *

Owner/Partner/Officer Name #1

Title

% of Ownership *

Street Address

City

State/Province

ZIP / Postal Code

Country

Mobile Phone

Home Phone

Social Security #

D.O.B

Owner’s E-Mail Address *

If you had a prior bankruptcy what type of bankruptcy was it? *BusinessPersonalNo Bankruptcy

If yes, date discharged (month/year)

Owner/Partner/Officer Name #2

D.O.B

Social Security #

Home Phone

Mobile Phone

Street Address

City

State/Province

ZIP / Postal Code

Country

Owner’s E-Mail Address *

% of Ownership *

If you had a prior bankruptcy what type of bankruptcy was it? *BusinessPersonalNo Bankruptcy

If yes, date discharged

Owner/Partner/Officer First Name #3

Owner/Partner/Officer Last Name #3

D.O.B

Social Security #

Home Phone

Mobile Phone

Street Address

City

State/Province

ZIP / Postal Code

Country

% of Ownership *

Owner’s E-Mail Address *

If you had a prior bankruptcy what type of bankruptcy was it? *BusinessPersonalNo Bankruptcy

If yes, date discharged

Owner/Partner/Officer Name #4

D.O.B

Social Security #

Home Phone

Mobile Phone

Street Address

City

State/Province

ZIP / Postal Code

Country

% of Ownership *

Owner’s E-Mail Address *

If you had a prior bankruptcy what type of bankruptcy was it? *BusinessPersonalNo Bankruptcy

If yes, date discharged

Trade Reference

Business Name *

Business Address *

City

State/Province

Zip /Postal Code *

Contact *

Telephone *

Account # *

MC / Visa / Discover / American Express Optblue

Annual MC/Visa/Discover Volume: *

American Express OptBlue® Annual Sales Vol. *

MC/Visa/Discover Average Ticket/Sales Amount *

American Express OptBlue® Average Ticket *

Highest Ticket Amount: *

Card Present Mag Swipe/Card Dipped/Contactless *

Card Present Not Swiped *

Keyed Manually *

Sales to Consumers *

Sales to Business *

Sales to Govt. *

Days to deliver order *

Prior Processor *

Bank Information

Bank Name *

Bank Contact Full Name *

Bank Contact Phone *

ABA # *

DDA # *

Let’s Get Started

Tell Us About Your Business

Billing Address

Provide Owner Information

Provide the following information for each individual who owns, directly or indirectly, 25% or more of the equity interest of your business.

Trade Reference

MC / Visa / Discover / American Express Optblue

Bank Information