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Merchant Pre-Application

Applying for a new merchant account is fast and easy! With our Merchant Account Pre-Application, you cant start accepting credit cards within 2-3 business days. Simply complete the form submit, and your will receive a complete application for your review and signature. For further assistance you may contact us at 818.702.0024 or toll-free 800.528.1782.
Owner/Officer/Principal Name*

PrefixFirst NameMiddle NameLast Name
Home Phone number

Area CodePhone Number
Mobile Phone number

Area CodePhone Number
Owner/Officer/Principal Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Percentage of Ownership*
Owner/Officer/Principal Date of Birth*

MonthDayYear
Driver's License Number*
Date Issued*
Date Expired*

Business Information
Applying as*

Sole ProprietorS CorporationClosely HeldPublic CorporationLLC (Limited Liability Corporation)
Business Legal Name (If Applicable)
Business DBA (Doing Business As)*
Business Phone *

Area CodePhone Number
Business Fax

Area CodePhone Number
E-mail of Applicant*
Business Location*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Website
Description of Products/Services offered*
Project Marketing Material

Upload a File

Cancelof

Disclosure

Submit my Application
The information provided in this application shall not be shared to anyone else and is kept confidential. I acknowledge that I am the business owner or authorized officer of the business and the information is true and correct. I agree that Credit Card Industry accepts no liability for the consenquences arising out of erroneous or incomplete information supplied by me.
I agree that the information herein are true and correct

Yes
Equipment Communication Method
Should be Empty:

Merchant Pre-Application