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. Furthermore, all information provided in this form is considered private and confidential in nature. Under no circumstances will your data be sold to nor shared with any outside party that has no direct involvement in the provisioning of service.
Email address *
Full Name (first, middle and last) *
Street Address (home) *
City & State *
Postal Zip Code *
Is your postal mailing address the same as your physical address? *
If Outside of the United States, Identify Your Country
Date of Birth (MM/DD/YYYY) *
Last Four Digits of Social Security Number (####) *
Percentage of Company Ownership? *
Primary Email Address *
Home Telephone Number (with area code) *
Mobile Telephone Number (with area code)
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