Corporate/Legal Name: *

Merchant Website: *

Doing Business As Name: *

Business Type: *

Federal Tax ID (if applicable) :

Products/Services:

Corporate/Legal Address:

City:

State:

Zip:

Business Type: * CorporationPartnershipLLCSole ProprietorshipOther

Business Phone:

Business Fax:

First Name:

Last Name:

Title:

Date of Birth:

% of Ownership:

Phone Number:

Email Address

City:

State:

Zip:

How long have you lived there:

Total Amount Monthly

Highest Ticket Amount:

Lowest Ticket Amount:

Recurring Payments: YesNo

Current Processor:

Other Payment Methods used (Diners, EBT, Checks, or Gift Cards):

Describe Products / Services Being Sold:

Describe Your Return Policy or All Sales Final: