Merchant Account Pre-Qualification Form
This Merchant Account Pre-qualification form is not a binding contract for service. This form enables our merchant account providers to identify the most suitable and cost affordable electronic processing solution for the applicant.
Email address *
Legal Business Name *
Legal Business Name
Your answer
Legal Business Address *
Legal Business Address
Your answer
City, State and Zip Code *
City, State and Zip Code
Your answer
Mailing Address (same as legal address) *
Required
Physical Address (same as mailing address) *
Your answer
Website URL (each website domain to accept transactions) *
Your answer
Website URL (2nd website domain to accept transactions. *If applicable)
Your answer
Customer Service Phone Number (w/area code)
Telephone Number
Your answer
Customer Service Email Address *
Your answer
Type of Business Entity *
Required
Business Tax ID Number or SSN *
Your answer
Bank Account: Routing Number (1st) and Account Number (2nd)
Your answer
Number of Locations (Stores or Offices)
Number of Locations
Your answer
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