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About
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What is merchant services?
Credit Card Terminals
Retail POS Systems
Restaurant POS System
Industries
Retail
Restaurant
Petroleum and Convenience Stores
Professional Services
Medical
Lodging & Hospitality
Contact
Get Started
Menu
Home
About
Solutions
What is merchant services?
Credit Card Terminals
Retail POS Systems
Restaurant POS System
Industries
Retail
Restaurant
Petroleum and Convenience Stores
Professional Services
Medical
Lodging & Hospitality
Contact
EZ Merchant Form Registration
Please enable JavaScript in your browser to complete this form.
1
BUSINESS DETAILS
2
OWNER INFORMATION
3
BANKING AND PROCESSING
4
EQUIPMENT
CONTACT INFORMATION
Name
*
First
Last
Email
*
Phone Number
*
BUSINESS INFORMATION
NOTE: Failure to provide accurate information may result in a withholding of merchant funding per IRS regulations. (See Part IV, Section A.4 of your Program Guide for further information.)
Business Legal Name
*
DBA Name
*
Tax Filing Name
*
Tax Filing Method
*
EIN
Type of Ownership
*
Government
Individual / Sole Proprietor
Limited Liability Company
Non-Profit Org
Partnership
Private Corporation
Public Corporation
Tax Exempt
Stock Exchange
NYSE or NASDAQ
Other/Not Applicable
Only applicable for Public Corporations
Stock Ticker Symbol
NYSE
NASDAQ
Not Applicable
Industry (MCC)
*
Business Description
*
Industry Options
FQuasi Cash
Business Start Date
*
Website
Business Phone
*
Business Address
*
Address Line 1
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Business Legal Mailing Address
*
Address Line 1
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Next
BUSINESS OWNER INFORMATION
Please provide the following information for each individual who owns, directly or indirectly, 25% or more of the equity interest of your business.
Name
*
First
Last
Title
*
CEO
CFO
COO
LLC Member
Owner
Partner
President
Secretary
Treasurer
Vice President
% Ownership
*
Personal Guarantee
Yes
SSN
*
Date of Birth
*
Mobile Phone
*
Email
*
Address
*
Address Line 1
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
ADDITIONAL BUSINESS OWNER (1)
Name
First
Last
% Ownership
SSN
Date of Birth
Mobile Phone
Address
Address Line 1
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Next
DEPOSIT BANK ACCOUNT
Bank Name
*
Account Type
*
Business Checking
Savings
Routing Number
*
Account Number
*
Attach Void Check
*
Click or drag files to this area to upload.
You can upload up to 50 files.
WITHDRAWAL BANK ACCOUNT
Withdrawal account is not required if it is the same as the Deposit account.
Bank Name
Account Type
Business Checking
Savings
Routing Number
Account Number
PROCESSING VOLUME
Average Monthly Card Volume ($)
*
per month
Average Transaction Amount ($)
*
MODE OF TRANSACTION
Must total 100%
In Person
*
Telephone
*
Online
*
PRODUCT / SERVICE DELIVERY WINDOWS
On average, Products / Services are delivered in
*
0–7 Days
8–14 Days
15–30 Days
30+ Days
Next
NEW ORDERS
Product Name
Network
Qty
Frequency
Product Name 2
Network 2
Qty 2
Frequency 2
Product Name 3
Network 3
Qty 3
Frequency 3
SHIP EQUIPMENT TO MERCHANT SERVICES
Ship To Attention
Ship To Email
Address
Address Line 1
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Confirmation
