Merchant Application Form

Are you an Owner/Officer of the company?

Yes

No

Do any of the following apply to you:
a) You use third party software or a payment gateway to process payments.
b) Have had a previous breach of cardholder data.
c) You store cardholder data -such as card number and expiry date on paper or on your computer/phone.

Yes

No

Do you wish to accept American Express cards?

Yes

No

If you already have an American Express Account Number, enter it here. Please leave it blank if none.

Does your business have internet service for use by the POS terminal?

Yes

No

Will be purchasing a POS terminal from us?

Yes

No

OPTIMIZING QUESTIONS