Online App 7.0

Please fill all required fields and don't forget to check the Accept Terms and Conditions checkbox

Please fill all required fields!

Steps

1 2 3 4

Please choose a bank

Default Bank

Merrick Bank

Low-Cost Guarantee

Qualified Rate

Transaction

Monthly Fee

Qualified Rate

Mid-Qualified Rate

Non-Qualified Rate

Transaction Fee

Monthly Fee

Interchange Rate

Transaction Fee

Monthly Fee

Qualified Rate

Transaction

Monthly Fee

Qualified Rate

Mid-Qualified Rate

Non-Qualified Rate

Transaction Fee

Monthly Fee

Interchange Rate

Transaction Fee

Monthly Fee

Amex Pricing

Qualified Rate

Non-Qualified Rate

Transaction

Amex Pricing

Qualified Rate

Mid-Qualified Rate

Non-Qualified Rate

Transaction Fee

Amex Pricing

Interchange Rate

Transaction Fee

Amex Pricing

Qualified Rate

Non-Qualified Rate

Transaction

Amex Pricing

Qualified Rate

Mid-Qualified Rate

Non-Qualified Rate

Transaction Fee

Amex Pricing

Interchange Rate

Transaction Fee

Business Information

Required *

Merchant Profile

Type of Ownership *

Market Type*

Retail

Restaurant

Supermarket

Lodging

MO/TO

E-Commerce

Emerging Market

Public Sector

Cash Advance

Other

Required *

Do you currently accept Visa/Master Card/Discover? *

No Yes

Is your business seasonal?

No Yes

Are customers required to leave deposit for goods/service?

No Yes

High volume months:

Do you offer warranties, dues, subscriptions, memberships, or extended services?

No Yes

Duration of benefits (in weeks)

Do you process recurring transactions?

No Yes

Do you accept prepayment (or a deposit) for your goods/ services? *

No Yes

What percentage of your total sales are prepaid? *

What percentage of the total cost is prepaid on average? *

Credit Card Information

Do you have multiple locations for your business?

No Yes

Sales Profile (must = 100%)

Current Total :

* Required

Card Holder Data Storage Compliance & Service Provider

***** PCI DSS and card association rules prohibit storage of track data under any circumstances. If you or your POS system pass, transmit, store or receive full cardholders data, then the POS software must be PA DSS(Payment Application Data Security Standard) compliant or you (merchant) must validate PCI DSS compliance (see 1(b) below and questions 3 and 4 must be completed). If you use a payment gateway, they must be PCI DSS compliant. *****

1. Have you ever experienced an Account Data Compromise "ADC"? * Required

No Yes

Date of Compromise:

a) Have you validated PCI DSS Compliance No Yes

b) Date of compliance, Report on Compliance "ROC" or Self Assessment Questionnaire "SAQ"?

c) What is the name of your Qualified Security Assessor "QSA" or Self Assessment Questionnaire (circle one "SAQ") A B C D

d) Date of last scan

2. Are you using a "dial-up" terminal or "TTC" No Yes

3. Do you or your Service Provider(s) receive, pass, transmit or store the "FCN" Electronically? Yes No

If yes, where is card data stored?

Merchant's location only

Other Service Provider

Primary Service Provider

Both Merchant and Service Provider(s)

Merchant's Headquarter / Corp office only

All apply

4. What Primary Service Provider/Software Developer did you purchase your point of sale "POS" application from

a) What is the name of the Service Provider/Software Developer's application

b) Do your transactions process through any other Service Provider?

Yes No

c) If yes, name the other Service Provider

Merchant Site Survey Report (To Be Completed by Sales Representative)

Zone: *

Commercial Industrial Residence

Where is the Merchant name displayed? *

Window Door Store Front

Location: *

Office Shopping Area Home Mixed Apartment Isolated Mall

Previous Processor: *

Reason for Leaving: *

Does the product and inventory appear legitimate? * Yes No

Does the Merchant use a Fulfillment House? *

Yes No

If yes, was the fulfillment house inspected? *

Yes No

Notes: *

Discount: * Monthly Daily

Rep Code:

Rep Name:

Owner/Officer Personal Information

Required *

Home Required * Own Rent

Required *

Will you have a second signer on this account?

Yes No

Second Owner Information

Required *

Home Required * Own Rent

Required *

Will you have a third signer on this account?

Yes No

Third Owner Information

Required *

Home Required * Own Rent

Required *

Will you have a fourth signer on this account?

Yes No

Fourth Owner Information

Required *

Home Required * Own Rent

Required *

Fees (Only if Applicable)

Chargeback Fee (per occurrence)

EDC AVS Fee (per occurrence)

Retrieval Fee (per occurrence)

Voice Authorization Fee (per occurrence)

Non-Sufficient Funds Fee (per occurrence)

Help Desk Fee (per occurrence)

Non Qualified Downgrade

Account Setup Fee

Annual Membership Fee

Monthly Statement Fee

Monthly Debit Access Fee

Monthly Regulatory Fee

Online Reporting Access

Annual PCI Compliance Fee

Terms & Agreements

Accept Terms & Conditions

Click Here to View the Terms and Conditions

Merchant Profile Analysis

Describe in detail the products or services you are selling:

Explain how and where you advertise your products or services (Please supply examples of any brochures, catalogs, web pages or any other item used for marketing):

Describe where inventory is stored and how you fill your orders (if applicable):

If your product is drop-shipped, please provide the name, address and telephone number for the company that will be drop-shipping for you:

Please explain, in detail, exactly what you will be charging the customer for:

For those providing a service, please explain billing policies (i.e. one time fee or monthly):

How far in advance will charges be made prior to fulfillment (shipping):

What is your cancellation policy and how do you advise a customer of your policy?

What is your refund policy, how long do your customers have to receive a refund and how should refunds be requested? (written, verbal, 30-day etc.)

Who records the credit card account number information and authorizes the sale on telephone sales (MOTO account)?:

Who is responsible for issuing customer refunds?:

Should we have any questions on any of your answers, what number should we use to contact you?

To Email:

Link To Finish Application

Direct:

Email:

Web:

Please be patient, it may take as long as
30 seconds to process your application.

Questions? Call (801) 623-4000 Opt. 9