Merchant Application

Business Information

Tax status

Tax-exempt entity

Corporate / legal name

Ownership / entity type

Street address

City

State

ZIP

Business founded

Federal Tax ID / EIN

Is your DBA the same as corporate/legal?

Yes No

DBA name (if different)

Website

Business Location

Building type

Shopping Center Office Building Industrial Building Residence

Corporate Contact

Business phone

Business email

Contact phone

Contact email

Fax number

History

Has the business or any principal ever been terminated from accepting bank cards?

Yes No

If yes, explain

List all principals owning 25% or more of the legal entity — combined ownership listed must total at least 51%. Sensitive fields (SSN, DOB) can be left blank and completed on the signed application.

Principal 1

First name

Last name

Title

Ownership %

SSN

Date of birth

Driver license #

DL state

DL expiration

Home address

City

State

ZIP

Phone

Email

Signer?

Yes No

Personal guarantor?

Yes No

Nationality

Bank Account

Bank account type

All Deposits Debits

Bank routing number

Bank account number

Bank accounts note

Payment Information

Does this business currently accept credit/debit cards?

Yes No

Monthly volume ($)

Average transaction ($)

Max transaction ($)

Card types to accept

Visa / Mastercard / Discover AMEX PIN Debit EBT

Product keywords

Seasonal business?

Yes No

Short description of business

Notes

Sales Method

In-person %

Mail/Phone %

Internet %

Must total 100%.

Refund and return policy

Equipment / software used to process cards

Customer Profile

Individual consumers %

Businesses %

Government %

Cardholders — local %

National %

International %

Fulfillment

Inventory maintained

On-Site Off-Site (Warehouse) 3rd-Party Fulfillment Center Service Only

Other companies involved in shipping/fulfilling?

Yes No

Recurring / time-extended services offered?

Yes No

Cardholder is charged at

Time of Order Upon Shipment

Retail location physical address (MOTO/internet merchants)

How do you advertise? List all that apply

Review your answers

On submit, Merchantic receives the application data and a completed fillable PDF. Pricing is finalized by Merchantic before anything is sent for signature.

Merchant application