Merchant Account Pre-Application

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* Legal Business Name (If you are not a Corporation or LLC, enter your Full Legal Name(s))

* Business DBA (ex. Widgets.com)This name should appear on your checks if you are not a Corp/LLC

* Business Address (if eCommerce, this address must appear both on your checks and website info section.)

* City

* State

* Zip Code

* Business Telephone Number

* Business Fax Number

* eMail Address

Mailing Address for Statement/Correspondence/VISA Compliance Mailings (If Different from Business Address)

City (If different from above)

State (If different from above)

Zip Code (If different from above)

* Date This Business Was Started (ex.. January 10, 2006 or 1/10/2006)

* Federal Tax ID or Social Security Number if Individual/Sole Proprietor

* Website Address (ex .. http://www.interchangepricing.com)

* Indicates Response Required