Merchant Application Form

Merchant Account Application

BUSINESS INFORMATION

Sales Representative ID Number:

Business Legal Name:

Business Name (DBA):

Check here if Corporate Headquarters.

Business Location Address:

City:

State:

Zip Code:

Phone:

Fax:

Business Fed. Tax ID:

Bank (or) Merchant Association:

Contact Name:

Email:

Website:

Billing same as Location? Yes No

Business Billing Address:

City:

State:

Zip Code:

Phone:

Fax:

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