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Merchant Application Worksheet

Once you have decided to sign up for our Free Virtual Terminal Program please fully complete this Merchant Application Worksheet. What we will do with this information that you provide is to transfer it to the original merchant application. We will then fax or email the application to you for your signature. Also included will be a checklist noting each of the items, if any, that we will need to process your application.

Business Information:
Business DBA Name
Legal Name
Street Address
State Zipcode

Business Phone Number (Including Area Code)
Fax Number (Including Area Code)

Which Legal Category Describes Your Business:

Please Briefly Describe Type of Product / Service Sold

Federal Tax ID Number (EIN) - Required if Corp. or LLC

Date Business Started (MMYY)

Trade Reference:
Business Name
Phone Number (including Area Code)

Landlord (If Applicable):
Landlord Name
Landlord Phone

Owner / Officer Information:

Owner’s Full Name
Owners' Title (Ex - Owner,President,Partner)
Street Address
State Zip Code

Home Phone (Including Area Code)

Email Address

Social Security Number

Date of Birth

If more than one owner please provide the above information for each owner in the comments section.

Bank Information:

Bank Name
Street Address
State Zipcode

Bank Phone Number (Include Area Code)

Routing Number (ABA) - 9 Digits on Bottom Left of Check
Checking Account Number

Additional Card Types:

Amexican Express

Yes No
I would like to apply for an American Express merchant account.
Here is my existing American Express SE number (10 Digits)

Discover Card

Yes No
I would like to apply for a Discover Card merchant account.
Here is my existing Discover Card merchant number (15 Digits)

Please fax a copy of a blank check in which you write Void across it to 215-489-7880. You can also scan and email it to Also, if you are currently accepting MasterCard/Visa please provide a copy of your latest monthly statement.

Questions or Comments:

All information is held in strictest confidence. Thank You.



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