Merchant Account Pre-Qualification Form
This Merchant Account Pre-Qualification form is not a binding contract for service. Information provided in this form allows our banking partners and merchant services providers to identify the most suitable electronic payment processing solution for the applicant. Information provided in this form is considered private and confidential in nature. Under no circumstances will your information will be sold to nor shared with any outside party that has no direct involvement in the provisioning of service.
Email address *
Legal Name of Company
Company Name
Your answer
Business Street Address
Business Street Address
Your answer
City & State
City & State
Your answer
Postal Zip Code
Postal Zip Code
Your answer
Is the postal mailing address the same as physical address?
Physical Address (if different from the address provided above)
Your answer
Website URL domain (www.)
Your answer
Which Website Builder Do You Use?
Do you sell from a retail store environment that requires credit card processing?
Number of Store Locations or Offices
Your answer
Primary Business Telephone Number (w/area code)
Telephone Number
Your answer
Customer Service Telephone Number (w/area code)
Telephone Number
Your answer
Customer Service Email Address
Your answer
Type of Business Entity
Business Tax ID Number or SSN
Your answer
Business Start Date (MM/YYYY)
Your answer
Gross Yearly Sales Volume (In US Dollars)
Your answer
Visa & MasterCard - average monthly processing volume
Your answer
Discover Card - average monthly processing volume
Your answer
American Express Card - average monthly processing volume
Your answer
Electronic Deposit | Bank Account Details: Routing Number (1st) and Account Number (2nd)
Your answer
Name Listed As Bank Account Holder
Your answer
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