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ACH Secure Merchant Application Worksheet

Business Information:
Business DBA Name
Legal Name
Address Line 1
Address Line 2
State Zipcode

Merchant Contact Name
Business Number (Including Area Code)
Fax Number (Including Area Code)

Your E-mail Address
Website Address (If applicable)

Federal Tax ID Number

Date Business Started (MM/YYYY)

Business Legal Status:

Product or Service Information:

Please Briefly Describe Type of Product / Service Sold

Current Check Volume ($)
Average Check Amount ($)
Estimated Maximum Transaction Amount ($)

Current ACH Provider (if applicable)

Method of Sales (must equal 100%):

Written Pre-Authorization – Company has obtained written authorization from the
consumer to debit/credit consumer’s depository account.

Non-Written Pre-Authorization – Company has obtained verbal authorization from the
consumer to debit/credit consumer’s depository account, but does not have written

Percentage of Products Sold Via (Must equal 100%):

Merchant Initiated – Merchant enters info into Virtual Terminal

Consumer Initiated – Consumer enters info via the Internet

Type of Business:

Business Credit References (2 Required)

Trade Name Contact Person Telephone (no 800 numbers)

Personal Information

Owner / Officer Name
Home Street Address
Home City
Home State
Home Zip Code
Home Telephone
Social Security Number
Equity %
Date of Birth (MM/DD/YYYY)

Banking Information

Bank Name
Bank Street Address
Bank City
Bank State
Bank Zip Code
Account Number
Bank Routing Number (9 digits)
Bank Account Number

Please fax a copy of blank voided check to 215-489-7880.

Questions or Comments:

All information is held in strictest confidence. Thank You.



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Compare Credit Cards to ACH

Credit Cards
Sale of $100
Discount Rate - 3%
Per Transaction - 30¢
- - - - - - - - - - - -
Your Cost for Credit

Sale of $100
Discount Rate - 0%
Per Transaction - 25¢
- - - - - - - - - - - -
Your Cost for ACH

Savings - $3.05
ACH Secure = More Money in Your Account


Today is
It is the perfect day to select ACH Secure
for your ACH processing service.


Credit Card Processing Services, Inc. is a
Registered ISO/MSP of Wells Fargo Bank, N.A., Walnut Creek, CA

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