Secure Merchant Application Merchant Applicaiton Your AIS Agent (if applicable) * Business Name: * DBA: * Radio Buttons * Sole Proprieter Partnership Corporation LLC EIN/TID: * Company Email Address * Business Address: * Business Address: Business Address: Business Address: City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Bank Routing #: * Account #: * (Submit copy of a voided business check if possible) Drop a file here or click to upload Choose File Maximum upload size: 262.14MB Website/URL Average Ticket: * High Ticket * Monthly Average Processing: * Years in Business: * Business Phone: * Owner Information Section Full Name: * Date of Birth: * Soc. #: * % Ownership * Driver License: * State Issued: * Home Address: * City * State: * Zip: * Cell #: * Additional Owner * Yes No Additional Owner Full Name: * Date of Birth: * Soc. #: * % Ownership * Driver License: * State Issued: * Home Address: * City * State: * Zip: * Cell #: * Additional Owner * Yes No Additional Owner Full Name: * Date of Birth: * Soc. #: * % Ownership * Driver License: * State Issued: * Home Address: * City * State: * Zip: * Cell #: * Additional Owner * Yes No Additional Owner Full Name: * Date of Birth: * Soc. #: * % Ownership * Driver License: * State Issued: * Home Address: * City * State: * Zip: * Cell #: * Submit If you are human, leave this field blank.
