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Please complete the following secure form to apply for a merchant account.
Legal Name
Legal Address
Legal Address Address Line 1
Legal Address Address Line 2 (optional)
Legal Address City
Legal Address State
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Washington DC
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennslyvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Legal Address Zip Code
DBA Name
Business Address
Same as my Legal Address
Business Address Line 1
Business Address Line 2 (optional)
Business Address City
Business Address State
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Washington DC
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennslyvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Business Address Zip Code
Tax ID (9 digits)
Ownership Type
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SoleProprietor
Partnership
Government
LLC C Corp
NonProfit
Trust Or Estate
Non US Entity
C Corporation
S Corporation
LLC Disregarded Entity
LLC Partnership
LLC S Corp
LLC SoleProprietor
Phone
Email
Ownership Start Date
Owner Name
Owner Address
Same as my Legal Address
Owner Address Line 1
Owner Address Line 2 (optional)
Owner Address City
Owner Address State
---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Washington DC
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennslyvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Owner Address Zip Code
Date of Birth
SSN
Average Transaction Amount
Average Monthly Sales
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