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Tags: address city state, agent telephone, boxes, business fax, business products, business representative, customer service telephone, digits, doing business, e mail, isp, mailing address, merchant application, partnership, sales representative, sole proprietorship, street address city, tax id,Pages: 2
Language: english
Created: Thu May 15 13:51:51 2008
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InstaPayment MERCHANT APPLICATION
Please print and fill out this form. Fax back to 866-497-1222
Agent Office InstaPayment-Corp_ Agent Telephone (866) 632-4325__ Sales Representative Staff ___
Legal Name of Business DBA (doing business as)
Merchant Information
Street Address (Physical addressno P.O. boxes) City State Zip
(Required)
Mailing Address (If different from Street Address) City State Zip
Telephone No. Business Fax No. Tax ID No. (Required--9 digits) Age of Business
( ) - ( ) - Yrs. Mos.
Authorized Business Representative Merchant E-Mail Merchant Customer Service E-Mail Merchant Customer Service Telephone No.
( ) -
List Type of Business/Products/Services Sold (Be specific) ISP or INFO@ E-Mail Merchant URL
51% ownership for a corporation, 100% ownership for a partnership or proprietorship, must be accounted for on the application
Sole Proprietorship Private Corporation Public Corporation Government (Federal/state/local)
Partnership Limited Liability Company Nonprofit Corporation Associations/Estates and Trusts
Medical or Legal Corporation International Organization Tax-Exempt Organization (501C)
Principal's Name Ownership % Title
Date of Birth (mm/dd/yyyy) (Required) Social Security No. (Required)
/ /
Driver's License No./State Issued ID (Required) Driver's Lic. State/Expiration Date (Required)
Ownership
/
Street Address (Physical addressNo P.O. boxes) City State Zip
Home No.
( ) -
Second Principal's Name Ownership % Title
Date of Birth (mm/dd/yyyy) (Required) Social Security No. (Required)
/ /
Driver's License No./State Issued ID (Required) State/Expiration Date (Required)
/
Street Address (Physical addressNo P.O. boxes) City State Zip
Home No.
( ) -
Direct Deposit Account designates account for electronic funds transfer (credits and debits) Merchant authorizes this account to be
electronically debited for amounts owing pursuant to the Merchant Agreement and this Merchant Application.
DDA
Bank Name Transit Routing No Deposit Account No. Telephone Bank Contact
( ) -
Merchant Marketing Method MerchantsPlease indicate type of business below
(Enter all that apply; must equal 100%) Retail (Must be at least 70% swiped)
Retail Card Present % Restaurant Tips? Yes or No
Marketing
Service % Keyed/Card-Not-Present (30% + keyed)
Trade Show % Merchant Swiped/Keyed Percentage (Must equal 100%)
Telephone Order % %Swiped
Internet % %Keyed With Signed Imprint
Mail Order % %Keyed Without Imprint or Signature
Purchasing Card % Requires Small Ticket application
Average Combined Monthly Volume 1 $ Average Ticket/Sales Amount 2 $
Are you now processing or have you ever processed MasterCard/Visa? No Yes (If yes, attach a previous processor's statement)
Processor
Name of Processor
Have you ever had a bankcard relationship terminated? No Yes (If yes, attach explanation)
Monthly Minimum $ Cust. Support $ Statement Fee $ Gateway Fee$
Quoted
Rates
Qual. Mid Non Interchange Fees $
CARDnet Platform Terminal Software
Omaha Platform Printer Turnkey
Equipment/
Software
Nashville Platform PIN Pad Other
Conversions/Existing Equipment REPROGRAM? YES NO
Terminal No. Printer No.
PIN Pad No. Other No.
© 2008 InstaPayment, Inc. - Page 1 of 1 - 0403
Please fill out this form and fax back to 866-497-1222
© 2008 InstaPayment, Inc. - Page 2 of 1 - 0403