Business Profile

Credit Card Processing Service

(Information for pre-qualification purposes only and not a guarantee of acceptance.)

The personal information you supply will be used for the purpose of qualifying you as a merchant account by Mercury Payment Systems. This information is held in the strictest confidence and is never sold, rented, or shared with any other business or third party.

Please fill out the form below. Fields with (*) are required.

Business Profile

DBA Business

* Business/DBA Name
  
* Street Address
 
City
State
* Zip
 
* Phone
  
Fax
Primary DBA Contact
  
Statement Address
 Use DBA

Legal Business
Same as DBA address
* Legal Business Name
 
* Street Address
 
City
State
* Zip
 
Phone
Fax
* Primary Legal Contact
 
Statement Address
 Use Legal

Business
* Owner/Officer Name
Email Address
Home Phone
Home Address
Home City
State
* Zip
Years at this Address
  Rent Own

Business Type
                    Sole Proprietorship Partnership Corporation LLC Tax Exempt
* Product or Service Sold
  
Federal Tax ID
Annual Visa/MC/Discover Sales
Years Business Owned
Total Number of Locations
Projected Processing Date

Application
                   Application for the following credit cards (select all that apply).
                    Visa/MasterCard/Discover American Express EBT Debit (with pinpad) JCB
FNS#
 (7 digits)
Existing Discover Merchant Number
 (15 digits)
Existing AMEX Merchant Number
 (10 digits)
   

Receiving Application
* New or Existing Business
 New    Existing
* Type of Merchant

Existing Service
                   Would you like the application Faxed or E-mailed?
Fax Number or Email Address
What is the best way to contact you?
 DBA Phone Cell Phone Email
Please add comments or questions here

Your Dealer’s Information

Contact Information
Dealership Name
Name/Primary Contact
Phone
Point of Sales System

Verification
Please fax a voided pre-printed business check to 970-385-3436

(The legal business name and or DBA name that is printed on the bank check must match this business profile exactly)