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Corporate & Merchant Services
LEADING BANKCARD ORGANIZATION * MERCHANT TRANSACTION PROCESSING SERVICES
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Merchant Application
form jpeg

 

 Please read carefully, and enter as much information as possible when filling out the application below. Applications are underwritten and approved by Patriot Bankcard or Merchant Processor

 
 

Business Information

 
Legal Business Name:
Federal Tax ID No:
D.B.A.:
Business Type:
Years in Business:
    
Location Address:
City:
State:
Zip:
Business Phone:
 - -
Email Address:
Web Site:
    

 

Banking Information

 
Bank Name:
Bank Phone Number:
 - -
Bank Routing Number:
(First set of numbers on bottom of check)
Bank Contact:
Bank Account Number:
Type of Account:

 

Owner/Officer Information

 
Owner/Officer Name:
First Name:
Last Name:
Owner/Officer Title:

If Other, Please Specify:

Percent of Ownership:
 %
Home Address:
City:
State:
Zip:
Residence:
Years at Current Address:
Home Phone Number:
 - -
Date of Birth: Yr:
Social Security Number:
 - -  
Drivers License Number:
Drivers License State:

License Expiration Date:
Please rate your credit:
  

Personal References (Some not living with you)
 

1)First Name:

Last Name:

Reference's Phone Number:
- -

Reference's Address:
City:
 State:
 Zip:
  
2)First Name:
 Last Name:
 Reference's Phone Number:
- - 		Reference's Address:
City:

State:

 Zip:
  
3)First Name:
 Last Name:
 Reference's Phone Number:
- - 		Reference's Address:
City:
 State:
 Zip:
  

Credit Information:
In what categories do you expect your sales to fall? (Must = 100%)
Retail % Mail Order % Trade Show % Service % Internet % Other %
Average Ticket Size: $ .00
Do you currently accept credit cards?
Expected Monthly Credit Volume:
Has any of the Owner's/Officer's of this organization ever had a Bank Card relationship terminated?
Questions or Comments:
 
 
Email: