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GENERAL INFORMATION:
Your Email Address:
Legal Business Name State D.B.A.
Business Address Suite City/State/Zip
Describe Business (Name Product/Service) Business Hours
% Mail Order % Phone Orders % Trade Show
# of Locs Year Started Fed Tax ID State Tax ID (If Retail)
Principal Contact Title Phone No. Fax No.
Est. Card $/Mo. Avg. $/Sale Type of Business
Sole Prop. Partnership Corp.
State of Incorporation Age of Business Date Acquired

OWNER/PRINCIPAL INFORMATION:

President/Owner Title % Ownership S.S.# (Req.)
Residence Address City/State/Zip
I Own I Rent, Since
Home Phone Prev. Address (if less than 3 years) D.O.B.
Co-Owner (If Applies) Title % Owned S.S.# (Req.)
Residence Address City/State/Zip Since
Own Rent

Business Location...Type of Building How Did You Find Total Merchant Services?
Commercial Residential Retail
Please Rank Your Credit Prior Chapter 7, 11, 13? Year
Excellent Fair Poor Yes No
Type of Processing Equipment (required to process credit card transactions)
Secure Internet Processing Software PC/MAC Software Terminal
Terms: Lease Purchase Reprogram Existing


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