Credit Card Processing Services Merchant Application Worksheet

The Best Merchant Account Programs For Your Business


 

Merchant Application Worksheet


Please use the Tab key on your keyboard to move from one field to the next. Using the Enter key will submit your form.

Business Information:

Business DBA Name
Legal Name
Address Line 1
Address Line 2
City
State Zip Code
How Many Years at this Address

Date Business Started (MM/YY)

Business Phone Number (Please Include Area Code)
Business Fax Number (Please Include Area Code)

Your E-mail Address
Website Address (If Applicable)

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

Which Legal Category Describes Your Business:

Product or Service Information:

Please Briefly Describe Type of Product / Service Sold

Estimated Monthly MasterCard/Visa $ Volume
Average Ticket
High Ticket

Owner's Information:

Owner's Full Name
Title (Ex - Owner, Partner, President)
Home Address
City
State Zip Code

How Many Years at this Address

Home Phone Number (Please Include Area Code)

Social Security Number

Date of Birth (Month/Day/Year)

Driver's License Number

Percentage of Ownership

If more than one owner please provide the same above information to CCPS for each owner. Please enter any additional owner information in the Comment section below.

Business Reference (Please Provide Two):

Name of Business
Contact Name
Reference Phone Number (Please Include Area Code)

Name of Business
Contact Name
Reference Phone Number (Please Include Area Code)

Personal Reference (Relative or Friend):

Name
Address
City
State Zip Code
Phone Number (Please Include Area Code)

Landlord of Business Location (If Renting or Leasing):

Landlord Company Name
Landlord Contact Name
Landlord Phone Number (Please Include Area Code)

Bank Reference:

Name of Bank
Bank Address
City
State Zip Code

Bank Contact Name (If Applicable)

Bank Phone Number (Please Include Area Code)

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

Additional Card Types:

American 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 Kevin@ccps.biz.

Yes No
I would like to purchase manual imprinter. It comes with a pack of 100 sales slips and a MasterCard/Visa decal. The cost is $35.00 + $6.00 shipping.

Questions or Comments:

All information is held in the strictest confidence. Thank You.

 


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