Credit Card Processing Application

Merchant Account Application

Please fill out the below application to the best of your knowledge.  

Company Information
Doing Business As Name (required)	Legal Name (if different from DBA)
Physical Address	Mailing Address (if different from physical)
City	City
State	State
AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNevadaNebraskaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOntarioOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming	AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNevadaNebraskaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOntarioOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Zip	Zip
Phone	Phone
( ) - ext.	( ) - ext.
Fax	Fax
( ) -	( ) -
URL (Web site address or DEMO server address) or eBay Seller's USER ID
Primary Email (please double check accuracy of your EMAIL Address)
Secondary Email (please enter an additional EMAIL address if you have one)
Please describe in SPECIFIC DETAIL the Products and/or Services that you offer; we are especially interested in a detailed description of the MAXIMUM DOLLAR AMOUNTS for your Products and/or Services that you expect to accept Visa/MC for. You may list individual products or categories of products:
Are your customers required to pay a deposit when ordering?(please respond) --- Please Select Option --- YES NO
What is your typical time frame until Product / Service is delivered?  # of typical days until delivery
What is your Refund/Exchange/Cancellation Policy?(please respond) --- Please Select Option --- All Sales Final Exchange Only Other  # of days that you will issue a full refund What is your Warranty Policy?(please respond) --- Please Select Option --- None (as is) Manufacturer Only In House   # of days that product is under full warranty IMPORTANT NOTICE: In order for your merchant account to be APPROVED quickly and efficiently by our Underwriting Department, you must clearly display your intended Refund, Exchange, Warranty or Cancellation policies (as applicable) on your Web site or Retail Store.

Merchant Profile
Business Open Date (i.e. 01/01/2004)	Monthly Visa/MasterCard Sales (Estimate)
	$
Federal Tax ID (or Social Security #)	Average Sale Amount per Credit Card
	$
	Maximum Sale Amount per Credit Card
	$

NOTE: Please be as realistic and accurate as possible in estimating your projected Visa/MasterCard monthly sales volume. This information is very important in approving your merchant acccount.

Do you currently accept Credit Cards? (please respond)

--- Please Select Option --- YES NO

If YES, is this with: a credit card TERMINAL for your RETAIL Store? a PAYMENT GATEWAY for this eCommerce site? a PayPal Account for your Website / eBay? other – please describe in Additional Comments section.

Ownership Information
Type of Ownership/Corporate Structure
Sole ProprietorLimited Liability Corp (LLC)Non Profit Organization (personal info required – Personal Guarantee will NOT be required)CorporationOther (please describe in Additional Comments)
First Name	Last Name
Title	Social Security Number
Date of Birth (i.e. 10 01 1958)
Are there additional Owners of the Company? (please respond) --- Please Select Option --- NO YES
Physical Home Address (not mailing address)
Street# Street Name Street Type Street Avenue Drive Road Boulevard Lane Place Highway
City	State
	AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNevadaNebraskaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOntarioOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Zip Code	Phone
	( ) - ext.

Name of Nearest Relative Not Living With You

Name of Relative	Phone Number of Relative (for emergency purposes)
	( ) -

Checking Account (may be Business or Personal Checking Account)
Bank Name	Contact Name
Address
City	State
	AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNevadaNebraskaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOntarioOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Zip Code	Phone
	( ) - ext.
Routing Transit Number (9 digits)	Account Number (include all zeros)

NOTE: We do not need your check #.

Additional Comments

We encourage you to include any additional comments you may have about your business, your policies (such as shipping / fulfillment) and your processing requirements. If your Web site is not complete, please include the URL of your demo site, and estimated time until your Web site will be completed.

Additional Payment Types
If you already accept American Express and/or Discover for the business (DBA) that this Merchant Account will be used for, please enter the appropriate account numbers below so we can activate them in our system. If you do NOT currently accept these cards for this business and wish to apply, you will need to select Please Apply below.
American Express
Processing Now Please Apply to accept American Express for your eCommerce business Not Interested
Please enter your current 10 digit account number from American Express.
Enrollment for Discover Card services requires an additional $25 one-time setup fee.
Discover
Processing Now Please Apply to accept Discover for your eCommerce business Not Interested
Please enter your current 15 digit account number from Discover Card.

* We will prosecute all Merchant fraud cases to the fullest extent and forward all Merchant and transaction information to the proper authorities along with all cancelled credit card numbers and persons attempting to use cards stolen or otherwise worthless as payment in any country or state.

e-onlinedata is a registered ISO/MSP of HSBC Bank USA, National Association, Buffalo, NY

©2003 All Rights Reserved