Posted on January 12, 2015 by admin Merchant InformationLegal Name of Business*DBA (Doing Business As)Best Contact Number*Email* Enter Email Confirm Email Business Phone Number*Fax NumberBusiness Address:* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Business InformationProducts or Services Sold*Type of Ownership:*Sole OwnershipPartnershipPublic CorporationPrivate CorporationNon Profit/Tax ExemptLimited Liability Corporation (LLC)GovernmentFederal Tax ID NumberBank 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:*Mostly SwipedMostly Over the PhoneThrough the InternetVariousEstimated Monthly Credit Card Sales*Estimated Individual Credit Card Sales*Yes, I would like a FREE CREDIT CARD TERMINAL (a $399.95 value): Yes Equipment*Ingenico ICT 220Ingenico ICT 220 Pin PadIngenico iWL 250Authorize.netGroovv StorefrontGroovv RestaurantGroovv TabletGroovv OneGroovv One PlusGroovv SwiperPayment JackDial Up or IPDial Up (Phone Line)IP (Through Internet Router)N/AOwner InformationOwner Legal Name* First Last Owner's Residential Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 IssuedDate Issued Driver LicenseExpiration Issued Driver LicenseSales AgentName: