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Merchant Application

Type of Account Applying For Credit Card
ACH E-check Services
   
Business Information
D/B/A name
Legal name
Address
City
State   ZIP    
Contact name
Contact email address
Corporate phone
Corporate fax
Web address
Total # Locations
Ownership: Proprietorship
Partnership
Corporation
LLC
Non-Profit
Type of Business

Retail
Wholesale
Restaurant
Lodging
Convenience Store
Supermarket
MO/TO
Home Business
Trade Fairs
Outside Sales/Services
Internet Only
Date established
Does this location currently accept VISA/MasterCard? Yes     No
Average ticket
Size of high ticket
Monthly average volume
                Or
Annual average volume
Sales method (Total must be 100) Retail Swiped %
Hand Key No Imprint %
Hand Key With Imprint & Signature %
   

Non-Bank Card
Do you need accounts in addition to VISA/MasterCard and do you have current accounts.

American Express
Do you have a current account? Yes No
Discover
Do you have a current account? Yes No
Diners/Cart Blanche
Do you have a current account? Yes No
   
Site Information Retail Storefront
Office/Warehouse
Residential
Other:
   
Owner — Officer Information — Two Required  
Owner/Officer Name #1
Title
Home address
City
State   ZIP    
Home phone
% of ownership
   
Owner/Officer Name #2
Title
Home address
City
State   ZIP    
Home phone
% of ownership
   
Have principals filed bankruptcy during the past two years? Yes     No
   
Trade References — Two Required  
Trade Reference Name #1
Contact
Phone
Account #
   
Trade Reference Name #2
Contact
Phone
Account #
   

Please ensure that all information provided is correct and complete prior to submitting this form. Please submit only once.

Please note: A hard copy of the merchant processing agreement (MPA) must be submitted. A follow-up call will be made to you within 24 hours to collect further information. In order to protect your identity, we do not ask for you to transmit over the Internet any confidential personal or business information. Once that occurs we will email you a completed application for your review and approval.  This application will require your authorization and will be sent back to us for approval. Thank you and please understand that submittal of this information by no means obligates you to anything. If you have any questions please call or email us first.

 

Privacy Policy: ©2012 Jacor Inc, Jacor Inc, All Rights Reserved. Jacor Inc dba/Cocard® is a registered agent of EDC Processing Services, a member of COCARD. COCARD is a registered ISO/MSP of Wells Fargo Bank, N.A. Walnut Creek, CA. COCARD is a registered ISO/MSP of First National Bank of Omaha, Omaha, NE. American Express® requires separate approval.  Powered by Verritech.