Merchant Application Form Business Info Products & Services Sold* Special Program MMC* First Name* Last Name* Secondary Contact Name Website Mobile* Fax Address* City* State* ZIP* Business Start Date* Years Owned* Months Owned* HQ Country Country of Formation Owner Information First Name* Middle Name Last Name* Title* N/A President Vice President Treasurer Owner Partner CEO Director Secretary Authorized Officer Date of Birth* SSN* Ownership* Owner Adress* Owner City* Owner State* Owner ZIP* Alternate Doc Included Beneficial Owner Authroized Signer Sole Proprietor Additional Owners Responsible Party? Previous Home Address Previous Country of Residence Previous City Previous State Previous ZIP Primary Id Document* Country of Issuance* Issuing State* ID Document #* Issue Date* Expiry Date* Other ID type Other ID number Issuing Country ID Name* Home Phone* Contact Us Email* Customer Service Phone Previous Processor Front Cover Sheet Company Application Personal Guarantee Application Worksheet Business Verification Other Addresses Mailing Shipping Special Instructions DBA Name* DBA Address DBA City DBA State DBA ZIP Phone # Fax # Statements Statements* N/A DBA Mailing W-9 Auto Send* N/A Yes No Retrievals* N/A Mail to DBA Mail to Legal Fax to DBA Fax to Legal OCM Retrievals Email* Chargebacks* N/A Mail to DBA Mail to Legal Fax to DBA Fax to Legal OCM Chargebacks Email* Other Company Info Number of High Sales V/M/D/UnionPay Sales # of Days CIP Exemption Beneficial Owner Exempt Months Closed Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Financial Info Bank Name* Routing #* DDA #* Routing #2 Account #2 % Card Present* % Card Not Present* % Internet* Average Ticket* High Ticket* Annual Credit Card Volume*
