Merchant Application

Please complete our user friendly Online Application to
INSTANTLY ESTABLISH
your Merchant Account and Payment solution!

Upon completion of the application, you will be presented with your Congratulations page containing your Schedule of Fees with instructions on how to proceed.

-PLEASE COMPLETE ALL DATA FIELDS-

Please do not click the BACK button of your Browser
or your may LOSE your data

Company Information

Doing Business As Name (required)

Legal Name (if different from DBA)

Physical Address

Mailing Address (if different from physical)

City

State

Zip

Phone

( ) - ext.

Fax

( ) -

URL (Web site address or DEMO server address) or eBay Seller's USER ID

Primary Email (please double check accuracy of your EMAIL Address)

Secondary Email (please enter an additional EMAIL address if you have one)

Please describe in SPECIFIC DETAIL the Products and/or Services that you offer; we are especially interested in a detailed description of the MAXIMUM DOLLAR AMOUNTS for your Products and/or Services that you expect to accept Visa/MC for. You may list individual products or categories of products:

Are your customers required to pay a deposit when ordering?(please respond)

What is your typical time frame until Product / Service is delivered?

# of typical days until delivery

What is your Refund/Exchange/Cancellation Policy?(please respond)

# of days that you will issue a full refund

What is your Warranty Policy?(please respond)

# of days that product is under full warranty

IMPORTANT NOTICE:
In order for your merchant account to be APPROVED quickly and efficiently by our Underwriting Department, you must clearly display your intended Refund, Exchange, Warranty or Cancellation policies (as applicable) on your Web site or Retail Store.


Merchant Profile
Business Open Date (i.e. 01/01/2004)	Monthly Visa/MasterCard Sales (Estimate)
	$
Federal Tax ID (or Social Security #)	Average Sale Amount per Credit Card
	$
	Maximum Sale Amount per Credit Card
	$

NOTE:
Please be as realistic and accurate as possible in estimating your projected Visa/MasterCard monthly sales volume. This information is very important in approving your merchant account.

Do you currently accept Credit Cards? (please respond)

If YES, is this with:

Ownership Information

Type of Ownership/Corporate Structure

First Name

Last Name

Title

Social Security Number (REQUIRED)

Date of Birth (i.e. 10 01 1958)

Are there additional Owners of the Company? (please respond)

Physical Home Address (not mailing address)

Street#	Street Name	Street Type

City

State

Zip Code

Phone

( ) - ext.

Name of Nearest Relative Not Living With You

Name of Relative	Phone Number of Relative (for emergency purposes)
	( ) -


Checking Account (may be Business or Personal Checking Account)
Bank Name	Contact Name

Address

City	State

Zip Code	Phone
	( ) - ext.

Routing Transit Number (9 digits)	Account Number (include all zeros)

NOTE: We do not need your check #.

Additional Comments

We encourage you to include any additional comments you may have about your business, your policies (such as shipping / fulfillment) and your processing requirements. If your Web site is not complete, please include the URL of your demo site, and estimated time until your Web site will be completed.


Additional Payment Types
If you already accept American Express under the same Legal name as you are applying under today (even if you are applying under the same Legal Name but with a NEW or DIFFERENT DBA Name) then you must contact American Express as they will require a new MID and will not allow e-onlinedata to apply for you. This is not applicable to Discover Card acceptance. Furthermore, if you already accept American Express at a retail location with the same DBA or Legal name as you are applying for today, please contact American Express as well, and request a second Merchant ID – American Express can be contacted at (800) 528-5200. If you do NOT currently accept Discover Card and/or American Express Cards for this business and wish to apply, you will need to select Please Apply below.
American Express

Please enter your current 10 digit account number from American Express.
Enrollment for Discover Card services requires an additional $25 one-time setup fee.
Discover

Please enter your current 15 digit account number from Discover Card.

* We will prosecute all Merchant fraud cases to the fullest extent and forward all Merchant and transaction information to the proper authorities along with all cancelled credit card numbers and persons attempting to use cards stolen or otherwise worthless as payment in any country or state.