Brick & Mortar Merchant Application

Please fill out this form as completely as possible. However, if there is any information that you do not have available or any question you do not understand, simply leave that section blank, and our staff will help you to obtain the missing information when we process your application. You will be contacted by one of our experienced merchant account consultants within an hour of submitting the application, and in most cases, we will have your merchant account up and running within 24 hours.

We do not share any of your information with anyone under ANY circumstances. All information you provide will remain confidential.

Merchant Information

Legal Name of Business	DBA

Street Address (Physical Address - No P.O. Boxes)	City	State	ZIP Code


Mailing Address (If Different from Street Address)	City	State	ZIP Code

Business Telephone Number	Business Fax Number
()	()

Tax ID Number	Number of Years in Business
	years months

Authorized Business Representative	Merchant E-Mail


List Type of Business / Products / Services Sold (Be Specific)	Merchant URL (if applicable)

Ownership
51% ownership for a corporation, 100% ownership for a partnership or proprietorship, must be accounted for on the application:

Principal's Name	Ownership %	Title

Date of Birth	Social Security Number
/ /

Driver's License Number / State Issued ID Number	Issuing State	Year Expiration

Street Address	City	State	Zip Code

Home Phone Number

()

Second Principal's Name	Ownership %	Title

Date of Birth	Social Security Number
/ /

Driver's License Number / State Issued ID Number	Issuing State	Year Expiration

Street Address	City	State	Zip Code

Home Phone Number

()

Processor
Are you now processing or have you ever processed MasterCard/Visa?
Have you ever had a bankcard relationship terminated?

Average Combined Monthly Volume	Average Ticket/Sales Amount

Choose Between a Card Swipe Terminal or Software for your PC or Palm OS device:

Swipe Terminal

Software
Palm OS Software (swipe cards on your Palm OS enabled PDA) - $175 for Mobile Processing Software and $25.00 per month for the Palm OS Wireless Payment Gateway.

PCAuthorize® for Windows
Single User Version: Purchase: $135 Lease To Own: $8.50/mo. for 24 months*

ICVERIFY® for Windows
Single User Version: Purchase: $315 Lease To Own: $20/mo. for 24 months*
Multi-User Version: Purchase: $450 Lease To Own: $$28/mo. for 24 months*

If you are interested in any of the Software's above - please check the box.

* All Leases are subject to a separate credit approval.

Copyright 2003 Pay-It Online, LLC & Cardservice International. All Rights Reserved.

MerchantAccounts4Less.com is a Pay-It Online LLC owned site. Visit us at www.pay-it.com.

Cardservice International is a registered service provider for the following FDIC-insured banks: First Financial Bank, Atlanta, GA; Humboldt Bank, Eureka, CA; Redding Bank of Commerce, Redding, CA; Tehama Bank, Red Bluff, CA.

American Express and Discover require separate approval.

Brick & Mortar Merchant Application

Merchant Accounts 4 Less