Credit Card Pay | Merchant Pre-Application

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Credit Card Pay Merchant Pre-Application

"*" indicates required fields

Step 1 of 5

Merchant Name (DBA or Trade Name)*

Corporate/Legal Name*

Location Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is the billing address the same as the address above?*

Billing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Customer Service Phone Number*

Customer Service Email*

Federal Tax ID*

Business Establishment Date*

Name - Principal #1*

First Last

Title*

% Owned*

Phone*

Email*

Date of Birth*

Social Security #*

Identification Type*

State/County of ID*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country