Secure Merchant Account Application

Business Info

Authorized contacts name.
Does your business have a legal name that is different than the DBA entered above?

Business Address

No PO Boxes or Mailing Centers - Must Be A Valid Office Address, Your Home Is Acceptable.


Please provide details for the bank account you will be using for merchant services

We will automatically debit your Settlement Account each month for the Monthly Fees on the last business day of each month. Your account will not be debited until the end of the Calendar Month. As a courtesy, applications submitted after the 15th of each month will not be charged the customary monthly fees unless you process transactions for this period.

NOTE: Failure to provide accurate information may result in a withholding of Merchant funding per IRS regulations. See your Program Guide provided at the conclusion of this application for your edification and for security procedures.

Owner Info

Owner Address