C Mart Technologies FREE Processing Application
Sales Representative Name *
Your answer
COMPANY INFO
Business Name *
Your answer
Location Address *
Your answer
Statement Mailing Address *
Your answer
Business Phone Number *
Your answer
Business Email *
Your answer
Business Website Address
Your answer
Corporate Name
Your answer
Corporate Address if different than above
Your answer
Tax ID / EIN # # - # # # # # # #
Your answer
Type of Business *
Statement Option Type *
Business Processing Category *
Merchandise/Services Sold *
Your answer
Years in Business *
Your answer
PROCESSING INFO
Currently accept Visa/MC/Disc/Amex *
Seasonal Merchant *
If Yes/Seasonal, which months are active?
Percent of Business (Must equal 100%)
Card Swipe % (50% or greater preferred)
Your answer
Manual Keyed %
Your answer
Phone/Mail Order %
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Internet %
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Average Ticket $ (Less than $350 preferably) *
Your answer
High Ticket $ (Less than $2K preferably) *
Your answer
Monthly Volume $ (Level 1 & 2 = <$150K & $150K+) *
Your answer
Transaction Descriptor to Appear on Statement (i.e. DBA) <24 characters
Your answer
Cust Svc Ph # to Appear on Statement (i.e. Merchant's Ph #)
Your answer
OWNER / OFFICER INFO (75%+)
Primary Contact Name *
Your answer
Primary Contact Title *
Primary Contact % of Ownership (51%+) *
Your answer
Residence Address *
Your answer
Primary Contact Date of Birth *
Your answer
Banking Info
Bank Name *
Your answer
Name on Bank Account *
Your answer
Checking Account # for Funding Merchant *
Your answer
Bank Routing # *
Your answer
Special Requests/Comments
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