This merchant application is...... powered by CPA Merchant Solutions.com
M E R C H A N
T A P P L I C A T I O N
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
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
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.
