Welocme to Merchant Account Checkup

Please fill out this form as completely as possible. However, if there is any information that you do not have available or any question you do not understand, simply leave that section blank, and our staff will help you to obtain the missing information when we process your application.

We are here to make sure that your merchant account application process is prompt and pleasant.

For your privacy and security, your account information is kept safe with the highest grade of commercially avaiable encryption. Your information will be kept completely confidential and will not be shared with anyone under any circumstances.

ONLINE APPLICATION

BUSINESS INFORMATION

Company Name:
Doing Business As (DBA):

Business Address: City: State: Zip Code:

Same as Biz
Shipping Address: City: State: Zip Code:

How long at Address: Time in Business:

Contact Name:

Business Phone: - - Business Fax: - -
Business Hrs:

Web Site: Business Email:

Ownership:

Type of Business (ex retail):

Federal Tax ID (Corp/LLC Only):

Products or services being Sold: # of Locations:

Currently processing credit cards or have in the past? No Yes, Processor's Name:

Have any of the owners ever had a merchant account terminated before? No Yes

Has merchant or any associated owner disclosed below filed for bankruptcy or been subject to any involuntary bankruptcy? No Yes

How did you find or hear about Gotmerchant.com?

PRINCIPAL OWNERS

Owner #1 Name: Title: Ownership (%):

Home Phone #: - - SSN: - -
DOB: - -

Same as Biz
Home Address: City: State: Zip:

How Long: Driver License #: DL State: Home Email:

If there is more than one owner, please list them below.

Owner #2 Name: Title: Ownership (%):

Home Phone #: - - SSN: - - DOB: - -

Home Address: City: State: Zip:

How Long: Driver License #: DL State:

Home Email:

BUSINESS REFERENCE

Company Name: Contact Name:

Phone #: - -

MERCHANT SERVICES

Your Anticipated Average Monthly Volume (ex $2,500 - You're not required to reach it)
Your Anticipated Average Credit Card Sale (ex $50)

How will you process most of your transactions?

% Through your web site (online store) by utilizing a shopping cart or similar product
% Swiping cards through a credit card terminal.
% Manually keyed-in (WITHOUT card imprint)
% Manually keyed-in (WITH card imprint - imprinter required)

100% - Total must add up to 100%

Want to Accept Discover Cards? No Yes | Existing Account #:

Want to Accept Amex Cards? No Yes | Existing Account #:

BANK DEPOSIT INFORMATION

Please include the bank information for the checking account you are using for the business. This is where the funds will be deposited. Double check for accuracy.

Bank Name: Phone: - -

City: State:

Routing Number (9 digits): Example:

Account Number: Example:

INTERNET & MAIL / PHONE ORDER

All merchants must fill out this section unless you are a retail merchant using a terminal machine (swiped transactions).

1. Type of merchant:

2. Please describe your products/services in detail:

3. Do you have a storefront? No Yes If Yes, street address:

4. Are orders received and processed at business location? No Yes

5. Where is the inventory housed?

6. Who provides order fulfillment services?

7. Describe your refund/cancellation policy (including restocking charges)?

8. Describe prizes or other incentives used to promote sales?

9. What is your "out of stock" policy?

10. Are deposits required for products/services? No YES, indicate the %:

11. Obtain customer's signature for delivery? No YES, explain the process:

12. Customer service number (will show up on customer's credit card statement)?

13. Does merchant charge for goods/services prior

to shipment? No Yes

Please indicate how long after the card is charged does a customer receive their purchase/service.

Within 48 Hours Within 2-5 Days Within 2-3 Weeks Other:

14. Merchant's web site url address?

You will receive your application by email with all your information pre-filled in. You simply complete, sign and send it back to us.


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	Person Name1 (Company Name, Country)



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	Person Name1 (Company Name, Country)

Name:

Email: