9 4R1
250 Corporate Blvd. Suite L
Newark, DE 19702
EXPRESS APPLICATION
Legal Business Name:
Legal Address:
Doing-Business-As Name:
DBA Address:
LLC, CORP, etc.: Age of Business:
Federal Tax ID: Business Phone:
Legal Name of Owner: Ownership%:
Job Title:
Home Address:
Email:
Website Address:
Home / Cell Phone: Social Security #:
Legal Name of Owner: Ownership%:
Job Title:
Home Address:
Email:
Website Address:
Home / Cell Phone: Social Security #:
877.517.4678 phone
PG #1
888.535.7463 fax
9-4R1
250 Corporate Blvd. Suite L
Newark, DE 19702
EXPRESS APPLICATION
Legal Name of Owner: Ownership%:
Job Title:
Home Address:
Email:
Website Address:
Home / Cell Phone: Social Security #:
Legal Name of Owner: Ownership%:
Job Title:
Home Address:
Email:
Website Address:
Home / Cell Phone: Social Security #:
Desired Method(s) of Accepting Payments:
Phone Line Wireless Internet Connected
Mobile Phone Virtual Terminal Shopping Cart
POS Name: Version:
Previous Processing? Yes / No AMEX
aily Settlement Time:
If Yes, How Long?
Average Ticket Amount:
Prev. Processor Name:
Average Monthly Volume:
Please include:
- A copy of a voided check
- A picture of your license
- Last 3 months of processing history (if applicable)
877.517.4678 phone
PG #2
888.535.7463 fax
