• Step 1
  • Step 2
  • Step 3
  • Step 4
  • Step 5
  • Step 6
  • Step 7
  • Final Step

I. BUSINESS INFORMATION



CORPORATE ADDRESS AND INFORMATION
 


PHYSICAL ADDRESS AND INFORMATION

YesNo




II. PROCESSING VOLUME (ALL CARD TYPES)

Percent of Business (MUST = 100%)

Sales Method (MUST = 100%)
 


III. PRODUCT ADVERTISING, SALES, AND DELIVERY ‐ ‐ REQUIRED QUESTIONS 1‐9 MUST BE ANSWERED ‐ MOTO QUESTIONS – 1‐17 MUST BE ANSWERED



*What percentage of your business is future services %  


*What percentage of your business is cash & carry %



Fed ExUPSAirborneUSPS Express


CatalogTV or RadioDirect Mail/FlyersInternet


By MerchantBy Manufacturer




MerchantVendor (Drop Ship Required)


YesNo
Months:

to



NoYes

(Percentage: %)


Incremental Payments

(Percentages % )










IV. Banking Information for Credits (for example: Deposits)

CheckingSavingsGeneral Ledger


DailyMonthly


Standard (1 Day Hold)Alternate Funding (Subject to approval)


Banking Information for Debits (for example: Fees)


CheckingSavingsGeneral Ledger

 



V. OWNERS/OFFICERS (MUST REFLECT OWNERSHIP OF 25% OR MORE)

* Ownership: Each individual who directly or indirectly owns 25% or more of equity interest of the within named legal entity MUST enter their Information .

Owner 1


Owner 2




Owner 3




Owner 4




Controller: Any individual with significant management responsibility (example: CEO, CFO, Treasurer, President, VP, etc.)
Controller
* Declaration
I hereby certify, to the best of my knowledge, that the information provided above is complete and correct.

Print Name:


Title:


Signature:

Date: