BANKCARD APPLICATION

apply for bankcard program

Please complete out the following preliminary application. Based on the information you provide us on the application, we will create a bankcard processing program proposal that we believe will fit your needs.

This is not a final document. You will not being obligated to purchase anything.

We are only able to accept businesses based in the United States.

All information that you supply to us will be kept confidential and will not be shared, sold or rented to any third party or other businesses.

LEGAL BUSINESS NAME

DBA NAME (if different from legal name)

BUSINESS OWNER#1 NAME

BUSINESS OWNER#2 NAME
(if applicable)

BUSINESS STREET ADDRESS

CITY

STATE

ZIP CODE

BUSINESS DESCRIPTION

NUMBER OF LOCATIONS

IF YOU ARE A MOBILE BUSINESS, HOW MANY OF YOUR EMPLOYEES WILL BE ASSIGNED A CREDIT CARD PROCESSING UNIT?

BUSINESS TELEPHONE#

BUSINESS FAX#

WEB SITE ADDRESS

BUSINESS EMAIL

YEARS IN BUSINESS

CELL PHONE #

DOES YOUR BUSINESS CURRENTLY ACCEPT CREDIT CARDS?

IF YES, WHAT IS YOUR AVERAGE MONTHLY CREDIT CARD SALES VOLUME?

DO YOU HAVE INTERNET ACCESS?

WHAT ARE YOUR CREDIT CARD PROCESSING INTEREST(S)? (please answer all that apply)

I WOULD LIKE TO BE ABLE TO ACCEPT CREDIT CARDS FOR MY RETAIL STOREFRONT BUSINESS.

I WOULD LIKE TO IMPLEMENT A GIFT CARD PROGRAM IN MY BUSINESS.

I WANT TO BE ABLE TO ACCEPT CREDIT CARDS OVER TE INTERNET.

I WOULD LIKE TO BE ABLE TO ACCEPT CREDIT CARDS FOR MY MOBILE BUSINESS.

I WOULD LIKE TO BE ABLE TO LOWER MY CURRENT PROCESSING RATES.

I WOULD LIKE TO BE ABLE TO ACCEPT CHECKS FROM MY CUSTOMERS.

I WOULD LIKE TO BE ABLE TO ACCEPT CREDIT CARDS FOR MY MAIL ORDER BUSINESS.

I WOULD LIKE TO ACCEPT DEBIT CARDS.

I WOULD LIKE TO ACCEPT EBT CARDS.

HOW IS YOUR BUSINESS OWNERSHIP ORGANIZED? (please select one box)

IF YOUR BUSINESS IS A CORPORATION, WHAT STATE AND YEAR WAS YOUR BUSINESS INCORPORATED?

STATE

YEAR