Merchant Pre Qualification Application
BUSINESS NAME(s)
MERCHANT RPOFILE
Sole ProprietorPartnershipPA or PCCorporationLimited Laibility co.Not for ProfitCity/ Goverment
YesNo
Ticket Size
The ticket size and monthly volume amounts are subject to credit approval
Bank Account Information
Bank Card Sales Profile
MERCHANT Type

RetailRestaurantServiceSeasonalInternetMOTOLodging/Car RentalB2BCity/Goverment

OWNERS/CERTIFICATION of Beneficial Owner(s)
Name and Title of natural person Opening Account

Federal Beneficial Owner(s) regulations require the above information for each individual who owns 25% or more of the legal entity and an individual responsible for managing the legal entity (e.g., Chief Executive Officer, Chief Financial Officer, Chief Operating Officer. Managing Member, General Partner. President. Vice President, Treasurer).

BUSINESS TRADE SUPLIERS
Name and Title of natural person Opening Account

MERCHANT SIDE PURCHASE REPORT
Merchant Location

Retail Location with store frontOffice BuildingResedenceOther

OwnsLeases the Business premiesResedenceOther

I hereby verify that this application has been fully completed by the Merchant Applicant and that I have physically inspected the business premises of the Merchant at this address, and the information stated above is true and correct to the best of my knowledge and belief.

MERCHANT SIDE SERVER REPORT
Name and Title of natural person Opening Account

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