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Credit Card Application

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Submitted on Jun 8, 2026 at 9:52 PM

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Credit Card Application

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Business Info - Content

Legal Name of Business^*

Address^*

Legal Phone^*

DBA Name and/or Address (same as legal?)^*

Yes

DBA Name^*

DBA Address^*

DBA Phone^*

Email Address^*

Website Address^*

Merchant Customer Service Phone^*

Date Business Opened (Month and Year)^*

Chargeback Notifications Email^*

Chargebacks Address^*

Legal

DBA

Statements Address^*

Legal

DBA

Contact First & Last Name^*

Contact Phone^*

Position in company (owner, admin etc.)^*

Any Prior Business Bankruptcies?^*

Yes

Any Prior Personal Bankruptcies?^*

Yes

Ownership and IRS W-9 Info - Content

Business Name (Exact business name submitted on your last income tax return)^*

Name of Contact for Secure IRS Related Information^*

Position in company (owner, admin etc.) for Secure IRS Related Information^*

Email of Contact for Secure IRS Related Information^*

Receive 1099K Statements Via Secure Email?^*

Yes

Type of Ownership^*

Tax Exempt^*

Yes

Type of Tax ID^*

EIN

SSN

ITIN

Tax Identification # (TIN)^*

Business Type^*

Description of Products or Services Sold^*

Owner/Officer Info - Content

Name^*

Job Title^*

U.S. Citizen/U.S. Resident^*

Yes

Social Security #^*

Date of Birth^*

% Ownership^*

Country Of Residence^*

Residential Address^*

Residential Phone^*

Add Another Owner's Info^*

Yes

Name^*

Title^*

U.S. Citizen/U.S. Resident^*

Yes

Social Security #^*

Date of Birth^*

% Ownership^*

Country Of Residence^*

Residential Address^*

Residential Phone^*

Add Another Owner's Info^*

Yes

Name^*

Title^*

U.S. Citizen/U.S. Resident^*

Yes

Social Security #^*

Date of Birth^*

% Ownership^*

Country Of Residence^*

Residential Address^*

Residential Phone^*

Processing Info - Content

Has Merchant Ever Accepted Credit Cards Before?^*

Yes

Processor Name^*

Number of Locations^*

Does Merchant Bill Their Customers Prior to Goods Being Shipped?^*

Yes

How Many Days Prior?^*

0-2

3-30

31-60

61-90

Over 90

What is your Return and Refund Policy? (Please be Specific)^*

Is This a Seasonal Business?^*

Yes

What type of credit card processing are we doing for you?

Card-Swiped Transactions %^*

Manually Keyed (Card Present with Imprint) %^*

Manually Keyed (Card Not Present and/or Mail Order/Telephone Order) %^*

eCommerce (Card Not Present)^*

Business to Business Sales % (Value must be 0 - 100%)*^*

Does Merchant Use a Third-Party to Fulfill Products or Services?^*

Yes

Projected Volume - Content

Average Transaction (Ticket) Amount $^*

Total Monthly Sales $^*

Does Annual AMEX Volume Exceed $1,000,000?^*

Yes

Would Merchant Like to Receive AMEX Marketing Materials?^*

Yes

Banking Info - Content

Bank Name^*

Routing #^*

Account #^*

Type of Account^*

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