Merchant Processing Application And Agreement

Download a blank fillable Merchant Processing Application And Agreement in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Merchant Processing Application And Agreement with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

M E R C H A N T P R O C E S S I N G A P P L I C AT I O N A N D AG R E E M E N T

(Page 1 of 4)

C O M P L E T E S E C T I O N S ( 1 - 9 )

Merchant #: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Loc. ______ of ______

GP1308(ia)

( 1 ) T E L L U S A B O U T Y O U R B U S I N E S S

GP1308(ia)

Client

Store #:

(Your Business LEGAL Name):

■ ■

Same as Legal Name or

Provide DBA / Outlet Name:

First / Last Contact Name:

Address:

Suite #:

City:

State:

Zip Code:

(No P.O. Box)

■ ■

Your Business Phone:

Same as Business Phone or

Merchant’s Customer Service Phone:

Your Fax Phone:

Select One for

Retrieval Requests:

■ ■

(02) Dedicated 24 Hour Fax

(03) No fax; mail

(05) eIDs

Your E-Mail Address

Your Customer Service E-Mail Address:

(Required for IP)

WebsiteAddress:

( 2 ) M C / V I S A / D I S C O V E R

N E T W O R K / A M E R I C A N E X P R E S S

O N E P O I N T

Your Total Cash and Credit Sales

Estimated MC / Visa Average Ticket / Sales Amount:

$ _____________

,000

$ _____________

(For All Outlets)

Estimated Discover Network Average Ticket for this Outlet:

$ _____________

Total Annual MC / Visa Volume:

,000

$ _____________

Estimated American Express Average Ticket for this Outlet:

$ _____________

(For All Outlets)

,000

Total Annual Discover Network Volume:

Annual MC / Visa Volume for this Outlet

$ _____________

(For Multiple Outlets Only)

,000

$ _____________

(For All Outlets)

,000

Est. Discover Network Annual Sales Vol. for this Outlet:

$ _____________

(For Multiple Outlets Only)

Total Annual American Express Volume:

,000

$ _____________

(For All Outlets)

Est. American Express Annual Sales Vol. for this Outlet:

$ _____________

(For Multiple Outlets Only)

( 3 ) E N T I T L E M E N T S

✓

■ ■

MC / Visa

Discover Network Full Processing (Discover Network systems and rules also process and govern JCB transactions. Elect JCB if a desired Card type.)

■ ■

Global ePricing (for eCommerce merchants only)

✓

■ ■

Voyager Fleet

Annual Voyager Vol.: $_______________

Participation in Voyager Tax Exempt Program:

Yes

No (if yes, additional request form required)

✓

■ ■

WEX Full Acquiring

Annual WEX Volume: $_______________

WEX (Non-Full Svc)

MC Fleet

2 8 0 9 0 0 9 9 0 1

■ ■

Non-Lic. JCB (EDC) ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ (Existing Account #)

JCB License ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

✓

■ ■

American Express

■ ■

OnePoint /Full Service (EDC)

ESA / Pass Through: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Existing SE # ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Amer. Exp. Cap # ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Franchise Name: ________________________________________________________________________________

Check one for ESA / Pass Through:

✓

7 7 7 3 6 2 0 5

■ ■

Split Dial

Single Settle

EDC

Reverse PIP

Debit Package ___ ___ ___ ___ ___ ___ ___ ___

EBT

FNS # (XREF): ___ ___ ___ ___ ___ ___ ___

■ ■

Gift Card

*Loyalty Solutions

Gift Card MID #: __________________________

Alt MID #: __________________________

*A separate Setup Form is required.

( 4 ) P R O V I D E M O R E B U S I N E S S D ATA

■ ■

State Incorp. ___ ___

Month/Yr. Started: __________

Sole Ownership

Partnership

Non Profit/Tax Exempt

Public Corp.

Private Corp.

L.L.C.

Gov’t.

✓

■ ■

Check one: TIN Type:

EIN (Fed Tax ID #)

SSN

D&B #: ____________________________

No. of Employees:_________

NOTE: Failure to provide accurate information may result in a withholding of merchant funding per IRS regulations (See Part IV, Section A.3 of your Program Guide for further information.)

■ ■

Name

Federal Tax ID#:

I certify that I am a foreign

(as it appears on your income tax return)

entity / nonresident alien.

(If checked, please attach IRS Form W-8.)

Mag Swipe ______ % + Keyed Manually ______ % = 100% Product/Services You Sell: ________________________________________________________________________

POS Card Present

______ %

Mail Order / Direct Marketing ______ %

Phone Order ______ %

Internet ______ %

= 100%

(MAG Swipe and/or Manual Imprint)

■ ■

Do you use any third party to store, process or transmit cardholder data?

Yes

(Examples include, but not limited to web hosting companies, Electronic Data Capture, Loyalty programs)

If yes, give name/address: ____________________________________________________________________________________________________________________________

Please identify any Software used for storing, transmitting, or processing Card Transactions or Authorization Requests: _____________________________________________

Client Initials_________