Online Application for new Merchant Account
Merchant Name
Please give us the name of sub-merchant you are adding
The customer service number for this sub-merchant, without hyphens.This is shown on the consumer’s statement if a value was not sent with the transaction.
Please give us the URL/website for this sub-merchant.
Indicates whether this sub-merchant should be enabled for eCheck Transactions (only seen if your organization is enabled for eCheck payment type).
Default Billing Descriptor
Max Transaction Amount($)
Customer Service Phone
Amex Merchant ID
Address 1
Address 2
City State Zip    
Enable eCheck Transaction
DBA Name
Please give us the name of your business or the DBA name as you would like it appear on your customers credit card statement
Also give us your Tax-ID and name, address information as it appears on your Tax return.
This information will be used to process your application for a merchant account.
Legal Entity Name
Legal Entity Type
Phone Number
City State Zip    
The date you started your practice?
Service location address
Address 1
Address 2
City State Zip
First Name                         Last Name
Enter then name and other contact information for the primary person responsible for operating the merchant account.
We will send you an email for verification that will contain a 'Verify' link.
The merchant account cannot be activated without the email verification.
Contact Name  
Date of birth
Number# State
Drivers License  
Phone Number
Mobile Number
FAX Number
Email Address
City State Zip    
Residential Address
Address 1
Address 2
City State Zip
How long have you lived there?
Are you renting or do you own?
Describe Product/Service
Please tell us about your business so that we can help you select the best rate for processing payment transactions.
Years in Business Select rate
Currently Accept Visa/MC?
Projected Annual Card Volume($)
Average Sale Amount($)
Checking Account Number
Please give us your settlement account where the proceeds of your transactions will be deposited. This will also be the account from where the processing fees will be drafted.
To ensure correct deposits please fax a voided check to:Fax Number: (316)-633-4244.
Bank Routing (ABA)
Voided Check