On-Line Processing Sign-up
Please complete all information on this form. Failure to complete this form will delay setting up your account.

You will be asked to provide your credit card information on the next page for your $ Sign-up Fee.

Business Name:
First Name:
Last Name:
City, State, Zip:
U.S. Federal Tax EIN:
(or Social Security #):
Telephone: -
Best Time To Call:
Fax: -
E-mail Address:
Your Website URLs:

Your Current Merchant Account Bank:


Your Current Merchant Account Bank Phone:


Current Merchant Account Processor:


Current Merchant Account Number:


Questions about your ISP


Where is your Website Hosted?


Who is your contact person there?


What is their phone number?


What is their email address?


What is their website address?


How Did You Hear About Us


Your Contact Person is


I have read and printed the Merchant Service Agreement. Yes    No


Notes and/or Comments.


Thank you for your business. Please submit this form and you will be contacted by staff to finalize the establishment your account.




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