Merchant Application Form

Business Info
Optimizing Ques
Ownership Info
Beneficial Ownership
Business Profile
Compliance
Merchant Bank
Fees

Equipment Setup
File Upload
Signature
Complete

EQUIPMENT SETUP

TERMINAL

QTY

PROVIDER CODE

Click to add more equipment or software (+)

PRINTER

PROVIDER CODE

PIN PAD

PROVIDER CODE

New Exchange

Other Equipment

PROVIDER CODE

EQUIPMENT SOFTWARE INFORMATION (+) Need to set if using 3rd Party software/gateway

Software Name

Publisher

Version

EQUIPMENT OPTIONS (+) The default selection will be applied for any option not selected

RETAIL / MOTO

AVS

Yes No

Last 4-Digits

Yes No

CVV 2

Yes No

Purchase Card/Level 2

Yes No

Invoice # Prompt

Yes No

PBX Code

8 9

Multi Merchant

Yes No

First/Master Merchant MID

Auto-Close++

Yes No

Auto Close Time

Store N Forward

Yes No

Pre-dial

Yes No

Cash Back

Yes No

Debit Cash Bank Max Amount

++ Auto-Close Time for Alternate Funding needs to be no later than 7:30 p.m. CST

RESTAURANT

Tips

Yes No

Servers

Yes No

Tables

Yes No

Bar Tab

Yes No

Suggested Tip

Yes No

PASSWORD

All

Yes No

Void

Yes No

Return

Yes No

Settlement

Yes No

Other

FAST PAY (FPS)

Yes No

Both receipts signature line

Yes No

Both receipts NO signature line

Yes No

NO receipts under $25.00

Yes No

Custom Header / Footer

Case Advance

Yes No

Lodging

Yes No

Fuel

Yes No

Wireless ID

Comments

EQUIPMENT SHIPPING INSTRUCTIONS (+) Required ONLY if ordering equipment - Default shipping options will be applied for any option not selected

Ship To

Merchant Location ISO Location Other

Ship Day

1-3 Day Over Night Priority Ground
Saturday

Payment For Equipment Will Be

Lease Check Cash Visa MC
Discover Amex 30 Day (Bill Group)

Attn

REPROGRAM/TRAIN MERCHANT?

Yes No

SHIP WELCOME KIT?

Yes No

Address

City

State

Zip Code

Phone

Special Instructions

Welcome Kit - Shipping Details - only if using different address

Ship To

Merchant Location ISO Location Other

Attn

Address

City

State

Zip Code

Phone

Action

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You will lose the data

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Please click continue to start the application from Business Information page.

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