Don't like online forms? click here to download this form in pdf format

Then Fax it to (805) 375-7506

BUSINESS NAMES
Business LEGAL Name:
Business Name/DBA Name:
Mailing/Billing Address:
City:
State:		Zip:
Contact Name:
Phone Number:
Fax Number:
Location Address (if different from Mailing):
City:
State:		Zip:
Country:
Contact Name:
Phone Number:
Fax Number:

MERCHANT PROFILE ("BUSINESS")
Business open Date:
Length of Current Ownership:
Number of Locations:
Expected Monthly Card Sales ($):
Average Ticket ($):
Type of Business
Type of Goods/Services Sold:
Current Processor, if applicable:
Site inspection performed:			Yes No
Seasonal Sales:			Yes No
	High Volume Months:
Method of Sale:
	Card Present:	%	Sales to Direct Consumer:				%
	Card Not Present:	%	Business to Business:				%
	Total:	100%	Total:				100%

OWNERSHIP INFORMATION
Ownership Type:
Federal Tax ID # (9 digits):
Owner 1/Partner/Officer Name:
Title in Business:
Equity Ownership:	%
Social Security #:
Home Address:
City:
State:		Zip:
Phone Number:
Owner 2/Partner/Officer Name:
Title in Business:
Equity Ownership:	%
Social Security #:
Home Address:
City:
State:		Zip:
Phone Number:

MERCHANT APPLICATION REFERENCES
Bank Reference:
	Name:
	Contact:
	Phone Number:
	Account #:
Trade Reference 1:
	Name:
	Contact:
	Phone Number:
	Account #:
Trade Reference 2:
	Name:
	Contact:
	Phone Number:
	Account #:

ADDITIONAL INFORMATION
Does your company or you, manage or own another business which already has a merchant account with Card Payment Systems? If yes, list Name Address and Merchant #:
Name of Business:
Address:
Merchant #
Have you or any principals of your company or any company you had a financial interest in, been previously terminated by another credit card processor or bank for VISA and MasterCard. If yes, please explain:
Important: I estimate that % of the VISA and MasterCard transactions that will be accepted by the business listed on this application will be present (either swiped though a credit card terminal or manually imprinted on a credit card sales draft) and % will be card not present (either telephone or mail orders).

FINAL SECTION

Please review all of the information above for accuracy and completeness and click the submit button.