CPA Merchant Solutions QuickBooks Software Check Deposit Processing

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M E R C H A N T A P P L I C A T I O N

PLEASE COMPLETE MERCHANT'S BUSINESS INFORMATION

MERCHANT INFORMATION

NAME OF ACCOUNT (DOING BUSINESS AS) NAME TO APPEAR ON CARDHOLDERS BANK STATEMENT

EXACT LEGAL NAME

DBA ADDRESS (IF DIFFERENT FROM LEGAL)

LEGAL ADDRESS - NOT A POST OFFICE BOX

CITY

STATE

ZIP

CITY

STATE

ZIP

CONTACT

TELEPHONE NUMBER

FAX NUMBER

E-MAIL ADDRESS

FEDERAL TAX I.D. NUMBER

WEBSITE ADDRESS

STATE TAX I.D. NUMBER

TYPE OF OWNERSHIP: SOLE PROPRIETORSHIP PARTNERSHIP CORPORATION LLC

MERCHANT PROFILE

MERCHANDISE/SERVICE SOLD	YEARS IN BUSINESS

LENGTH OWNERSHIP	# OF LOCATIONS	MONTHLY VOLUME	AVERAGE TICKET AMOUNT	HIGHEST TICKET AMOUNT

PERCENT OF BUSINESS

CARD SWIPED	%
VIRTUAL TERMINAL	%
MAIL ORDER / TELEPHONE ORDER	%
TOTAL	100%

HAS MERCHANT OR ANY PRINCIPAL BEEN TERMINATED AS A VISA / MASTERCARD MERCHANT (TMF)?

YES NO REASON:

HAS MERCHANT OR ANY PRINCIPAL DISCLOSED BELOW FILED BANKRUPTCY OR BEEN SUBJECT TO ANY INVOLUNTARY BANKRUPTCY?

YES NO REASON:

HAS MERCHANT PREVIOUSLY ACCEPTED CREDIT CARDS?

YES NO PROCESSOR:

HOW MANY CHARGEBACKS IN PREVIOUS YEAR?

WHAT WAS DOLLAR AMOUNT OF CHARGEBACKS IN PREVIOUS YEAR?

HOW DO YOU ADVERTISE? - CLICK ALL THAT APPLY INTERNET TV DIRECT MAIL OTHER

DOES MERCHANT CONDUCT BUSINESS SEASONALLY? YES NO	WHEN IS THE CARDHOLDER BILLED FOR PRODUCTS & SERVICES? ON ORDER WHEN DELIVERED
DOES THE BUSINESS USE ANY THIRD-PARTIES IN THE PAYMENT PROCESS? YES NO	DELIVERY OF SERVICE / PRODUCTS: TIME OF SALE 1 MONTH 2 MONTHS OTHER
IF YES, PLEASE LIST:	REFUND POLICY:
Merchant certifies that the average ticket size, highest ticket and sales volume indicated is accurate and acknowledges any variance to this information could result in delayed and/or withheld settlements of funds and/or termination of merchant.

INTERNET INFORMATION

LIST ALL ADDITIONAL URL'S FOR YOUR WEBSITE:	DO YOU USE A BACK-END LAW FIRM OR FULFILLMENT CENTER? YES NO IF YES, PLEASE LIST CONTACT INFORMATION:

OWNERS OR OFFICERS

PRINCIPAL #1 --- FIRST NAME & LAST NAME

% OF EQUITY OWNERSHIP .

PRINCIPAL #2 --- FIRST NAME & LAST NAME

% OF EQUITY OWNERSHIP

SOCIAL SECURITY NUMBER DATE OF BIRTH

TELEPHONE NUMBER

SOCIAL SECURITY NUMBER DATE OF BIRTH

TELEPHONE NUMBER

RESIDENCE ADDRESS

CITY

STATE

ZIP

CITY

STATE

ZIP

REFERENCES

TRADE REFERENCE	CONTACT

ACCOUNT NUMBER	TELEPHONE NUMBER

TRADE REFERENCE	CONTACT

ACCOUNT NUMBER	TELEPHONE NUMBER

REQUESTED CARD TYPES

VISA DEBIT

VISA CREDIT

AMERICAN EXPRESS

MASTERCARD DEBIT

MASTERCARD CREDIT

DISCOVER

BANKING INFORMATION

NAME OF MERCHANT'S BANK	CONTACT

BANK LOCAL TELEPHONE NUMBER

	ROUTING / ABA NUMBER
ACCOUNT TYPE: CHECKING

DDA / CHECKING ACCOUNT

Your message:

Approval amounts and terms are based on personal and business credit and time in business. Our specialty is providing the lowest rates and best value available with minimal documentation required. Upon receipt of this form, one of our Senior Merchant Representatives will contact you immediately.