Business Profile for Mercury Payment Systems
CREDIT CARD PROCESSING SERVICE
(Information for pre-qualification purposes only and not a guarantee of acceptance)

Please Note: 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.

* Required fields.
DBA Business
  Business/DBA Name:
 
  Street Address:
 
City:
State:
 Zip:
 
Phone:
 
Fax:
Primary DBA Contact:
 
Statement Address: Use DBA
 
Legal Business If the same.
Legal Business Name:
 
Address:
 
City:
 State:
 Zip: 
 
Phone:
Fax:
Primary Legal Contact:  
 
Statement Address: Use Legal

  Owner/Office Name: E-mail Address:
 
  Home Phone:  

Home Address:
 
City:  State:
 Zip:  Years at this address:         Your home:     Own   Rent  
 
       
 

Business Type:

  

Sole Proprietor

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 for the following Credit Card (select all that apply):
Visa/MasterCard/Discover Debit (w/Pinpad) FNS#  (7 digits)
American Express JCB Existing Discover Merchant Number:  (15 digits)
EBT   Existing AMEX Merchant Number:  (10 digits)

 

Would you like the application Faxed or E-mailed?

(Enter the FAX number or E-mail address.)

 
  What is the best way to contact you?  

DBA Phone

Cell Phone

E-mail

 
 

Please add comments or questions here:

 

 

 

 

 

Dealership Name:

 
 

Dealer Name/Primary Contact:

 
  Dealer Phone:     Point of Sale System:     

 
 

* Required fields.