Local Card Guy Credit Card Processing and Point of Sale

New Paragraphte

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PRE-APP/SETUP FORM

Pre Application for Merchant Account Agreement

Business Legal Name

DBA Name

Business Address

City

State

Zip

Business Phone

Business Fax

Email Address

Products/ Services Sold

Fed Fax ID

Fed ID Month/ Year Started

Tax Filing Type

Sole Proprietor

Partnership

Corporation - Public

Corporation - Private

Tax Exempt Organization?

Yes

No

Number of Employees

Total Gross Annual Sales

Estimated Annual Credit Card Sales

Estimated Average $$ Credit Card Individual Sale Amount

Estimated Highest $$ Credit Card Individual Sale Amount

Signor/Owner Name

Signor Title

Signor Percentage ownership in company

Signor Social Security #

Signor Date of Birth

Signor Home Phone

Signor Home Address

City

State

Zip

Deposit Bank Name

Bank Account Number

Bank Routing Number

Bank Phone

Do you have equipment you want to reprogram?

Yes

No

If Yes, enter Manufacturer and Model Number here:

If any external devices (pin pad, check reader, etc.) enter here

Date needed for start of service

Is this flexible?

Yes

No

Thank you!
We will get back to you as soon as possible.

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Pre Application for Merchant Account Agreement

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