First Data™

Select which payment methods you would like to accept: Visa/MasterCard American Express Discover TeleCheck Online Check Svc

Select Business Type: (check all that apply) Internet Retail Mobile/Wireless Mail/Telephone Order

Enter Bankcard Estimates:

Combined Estimated Monthly Volume: $

Estimated Highest Ticket/Sales Amount: $

Typical Ticket/Sales Amount: $

Processing Method: ( Total Processing Method must equal 100% )

Card Swipe Manually Keyed Internet MOTO

Have you ever had a merchant account before? Yes No

Type of Processing Solution Desired:

Credit Card Terminal
Online Processing Gateway/Software
Reprogramming for Existing Merchant Account

I Prefer To:

Buy Processing Solution
Lease Processing Solution

Legal Business Name: *

Business Address: *

City: *

State: * Please select your state Alabama Alaska Arizona Arkansas 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

Zip Code: *

Business Telephone: *

Business Fax:

Email Address: *

URL (if applicable):

Years In Business?: Years

Product/Service Sold:

Type of Ownership: Please select ------------------------------------ Sole Proprietor Partnership Corporation LLC Non-Profit Organization Government

Percentage of Ownership in Business: %

First Name: *

Last Name: *

Residential Address

City:

State: Please select your state Alabama Alaska Arizona Arkansas 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

Zip Code:

Years at this address: Years

Telephone:

Lead Source: Please select FICPA Existing Merchant Internet Yellow Pages Advertisement/Mailer

Comments/Questions: