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Merchant Information
Legal Name of Business*
DBA (Doing Business As)
Best Contact Number*
Email*
Enter Email Confirm Email
Business Phone Number*
Fax Number
Business Address:*
Street Address City State ZIP Code
Business Information
Products or Services Sold*
Type of Ownership:*
Federal Tax ID Number
Bank Name*
Routing Number*
Account Number:*
I have verified my bank account number and routing number to be correct:*
- Yes I have verified my bank account and routing number
Please provide sales method of how credit card orders will be received:*
Estimated Monthly Credit Card Sales*
Estimated Individual Credit Card Sales*
Yes, I would like a FREE CREDIT CARD TERMINAL (a $399.95 value):
- Yes
Equipment*
Dial Up or IP
Owner Information
Owner Legal Name*
First Last
Owner's Residential Address*
Street Address City State ZIP Code
Home Phone Number*
Owner's Date Of Birth*
MM
DD
YYYY
Owner's Social Security Number (for I.D. verifcation purposes only):*
Driver License # (Elavon App Only)
State Issued
Date Issued Driver License
Expiration Issued Driver License
Sales Agent
Name:

Merchant Information