BUSINESS INFORMATION
Legal Name of Business: DBA:
EIN/Tax ID: Business Start Date: State Filed:
Business Type:
☐Sole Prop ☐Corporation ☐LLC ☐Non-profit (401(c)) ☐Gov ☐Other
Street (Location) Address:
Mailing (Legal) Address:
Business/Contact Telephone: Business/Contact email:
Business Fax #: Customer Service Telephone:
Customer Service email: Website/URL*: http://
Authorized Contact First/Last Name:
Equipment/Gateway: (VX 520 Terminal, Authorize.net Gateway, NMI Gateway, etc.)
Shopping Cart (if applicable):
(If using Shopify, please request Authorize.net Gateway)
Number of Employees: Location: ☐Home/Residential ☐Office/Business District ☐Storefront
Approximate Sq. Footage: ☐0-500ft. ☐501-2,000ft.
Own or Rent: ☐Own ☐Rent
☐2,001-5,000ft. ☐5,000ft.+
PRINCIPLE INFORMATION
Full Name:
Ownership % (Include all w/25%+ equity):
☐Check here if there are Additional Owners/members with 25%+ equity
Title (Owner, CEO, President, etc.): Home Telephone:
Date of Birth: Social Security Number:
Driver License Number: Exp Date: State:
Home Address:
Personal Email Address:
SETTLEMENT ACCOUNT INFORMATION
Bank Name: Contact Name:
Band Routing Number:
Bank Account Number :
LIST TYPE OF BUSINESS/PRODUCTS/SERVICES SOLD:
PROCESSING VOLUME
Estimated TOTAL Monthly Volume (Cash, Checks, ACH, etc.): $
Estimated Monthly Volume (Visa/MC): $
Estimated Monthly Volume (American Express): $
Average Ticket: $ Highest Ticket: $
TRANSACTION METHOD (select all which are applicable – Must equal 100%)
☐ Face-to-face (Retail/storefront, cardholder is Present): %
☐ **Telephone/Mail/Email (MOTO, cardholder is Not Present): %
☐ **Internet (eCommerce, online Shopping Cart): %
RETURN POLICY / HISTORY
Do you have a refund/cancellation policy for Visa/MC/Discover/Amex Sales: ☐Yes ☐No
Check one : ☐Exchange ☐Store Credit ☐Refund within 30 days ☐Other*
If Other*, please explain:
Any processing history? ☐Yes ☐No
*If Yes, please provide 3-most recent Processing Statements
*Name of any current &/or previous Processors:
Have you ever had a payment relationship terminated? ☐Yes* ☐No
If Yes*, please explain:
Any Bankruptcies? ☐Yes* ☐No
If Yes*, please explain:
B2B: % B2C: % Is your business Seasonal? ☐Yes ☐No
Is there a recurring/subscription element to the business transactions? ☐Yes ☐ No
If yes, please specify:
CARD NOT-PRESENT & ECOMM/ONLINE MERCHANTS
List the name(s)/Addresses where the product is purchased:
Who owns the product(s)/inventory? ☐Merchant ☐Vendor (drop ship required)
List the name(s) of Fulfillment house, if any:
List the name(s) of Shopping Carts and/or CRM provider(s), if any:
How does the customer purchase/order the product?
☐In person ☐By Mail/phone ☐Internet/Website ☐By Fax ☐Other
List the name(s) of Call Center providers, if any:
Business Description: Length of Operations:
If you sell products, where are they stored?
When you receive Authorization, how long before the merchandise/service is shipped?
☐0-7 days ☐8-14 days ☐15-30 days ☐30-90 days ☐90+ days
What is the delivery time frame of the product/service to the customer?
☐0-7 days ☐8-14 days ☐15-30 days ☐30-90 days ☐90+ days
List the name(s) of Chargeback Management Systems, if any:
Any Deposits required? ☐Yes ☐No *If Yes, what’s the deposit %?
At what point has the customer paid in full?
☐100% Paid in Advance ☐100% Paid upon delivery/completion
In what geographic areas will the product(s) be marketed & sold?
What % of sales transactions are international cards? %
What Shipping service do you use to deliver products to customers?
☐FedEx ☐UPS ☐US Postal Service ☐Other, specify:
How do you Advertise? ☐Catalog ☐TV/Radio ☐Direct Mail/Flyers ☐Internet ☐Other
What is your Warranty / Guarantee? ☐By Merchant ☐By Manufacturer
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