Business Information:
Legal Business Name 
   DBA Name 
  Location Address 
  City, St, Zip 
 County
 Phone  Fax 
   Email 
 Web-Site (if Internet Account)
Partnership Corporation Sole Proprietorship
 Federal Tax ID   Years In Business

Checking account information:
List where you would like your funds to be deposited:
Bank Name, Branch
Account Number Routing Num.

Personal information:
Principal Name 
Title  % Percentage ownership
Home address
City, Sate, Zip
Years at current address
Previous Address (if less than 3 years)

Home Phone    Date of Birth
Social Security #
Drivers License #  State of issue  Exp

Apx. Monthly Volume $ Average Sale $

I wish to establish an ACH merchant account. I understand this application is refundable only if I am declined for an ACH merchant account*. I understand when I submit my application the $199 will be deducted from my checking account listed above. Additional paperwork will be required for setup to be completed and will arrive in the mail. If I decide to cancel the account application after submitting this form, or if my final paperwork is not signed, completed and returned within 30 days, my fee will be retained without exception.