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

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

Business Address Zip Code

Tax ID (9 digits)

Ownership Type

Phone

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

Owner Address Zip Code

Date of Birth

SSN

Average Transaction Amount

Average Monthly Sales

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