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Authorize.Net Products and Service
Ê Merchant BankCard Application
Legal Name:
Ê ÊDBA:ÊÊ
Billing Address:
City: Ê State: Ê Zip:
Location Address:Ê
City: Ê State: Ê Zip:
URL http://www.
Email:
Business Telephone: Ê Fax:
Fed Tax ID: Ê(If Corporation)
Type of Business:
Products Sold:
Date Business Started:
Visa/MC Average Ticket: $Ê Visa/MC Monthly Sales Volume: $
Ê Merchant Contact Information
Name: ÊTitle:
Home Address:
City: Ê State: Ê Zip:
Telephone: Home Ê Work
Date of Birth: Ê Social Security Number: Ê
Percent of Ownership: %
Ê Two Trade References and Bank Information (Required)
Business Name 1:
Contact Name:
Telephone:
Business Name 2:
Contact Name:
Telephone:
Bank Name:
Contact Name:
Telephone:
Ê If location address is NOT home address, supply Landlord information
Home Based: ÊYesÊÊÊÊNo
Landlord Name:
Contact Name:
Telephone:
Have you had a bankruptcy in the past 10 years? ÊNoÊ Yes
How is your credit?? ÊGoodÊ FairÊ Questionable?
We can get you a copy of your credit report if you're not sure.
State Return Policy: Ê(Money back guarantee etc.?)
Delivery time Frame?
Comments
Ê

 
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