merchant accounts

Please fill out this form as completely as possible. However, if there is any information that you do not have available or any question you do not understand, simply leave that section blank, and our staff will help you to obtain the missing information when we process your application. We are here to make sure that your merchant account application process is prompt and pleasant.

*Merchant Processing Services Inc, is a registered ISO/MSP of Harris, N.A., Chicago, IL



Legal Name
Legal Address
City:		State:		ZIP:
Phone Number:	( ) -		Please check if DBA information the same.

DBA Name
DBA Address
City:		State:		ZIP:
DBA Phone:	( ) -		Federal Tax I.D.
Fax Number:	( ) -		Years in Bus: Years Owned Bus:
Web address		E-mail
Casio Register#:		Bank Ref


Owner's Name:
Date of Birth	/ /	Applicant's SS#:
Home Address
City:		State:		ZIP:
Owner Phone:	( ) -


Ownership Type:		Do you currently accept Visa/Mastercard?
Type of Goods or Services Sold:


Merchant Type:

Yes, I want to participate in the optional Merchant Benefits which includes equipment support and replacement for an additional $9.50 per terminal per month, click this box:

I represent that the information I have provided on the Application is complete and accurate and I authorize American Express Travel Related Services Company, Inc ("American Express") to verify the information on this Application and to receive and exchange information about me, including, requesting reports from consumer reporting agencies. If I ask American Express whether or not a consumer report was requested, American Express will tell me, and if American Express received a report, American Express will give me the name and address of the agency that furnished it. I understand that upon American Express' approval of the business entity indicated above to accept the American Express Card, the Terms and Conditions for American Express Card Acceptance ("Terms and Conditions") will be sent to such business entity along with a Welcome Letter. By accepting the American Express card for the purchase of goods and/or services, you agree to be bound by the Terms and Conditions , click this box:

I agree to accept Discover Network Cards. Discover Network will deliver a starter kit with my merchant services agreement and materials , click this box:

*requires 3 year service agreement with associated fees. Early termination fee of $195.00 applies.

** By Federal Law, All Information Provided Will Remain Confidential **