Webmasters.com ~ Merchant Account Application

Business Information

Legal Business Name:

Doing Business As:

Contact Information

Contact Name:

Email Address:

Mailing Address:

Phone Number:

City / State / Zip:

Fax Number:

Country:

Billing Address is same as Mailing Address

Billing Address:

Website URL:

City / State / Zip:

# Of Locations:

Country:

Goods/Services Sold:

Time in Business:

Monthly Sales:

Average Sale Amount:

Current Ownership:

Years

Months

Do you currently accept credit cards? Yes No
Have you ever had a credit card merchant account terminated? Yes No

If you answered "Yes" above, please explain:

Ownership Information

Type of Ownership:

Federal Tax ID#:

Principal One

Principal Two

Name:

Title:

% Of Ownership:

Social Security Number:

Drivers License Number:

Date Of Birth:
(mm/dd/yy)

Home Address is same as Mailing Address

Street Address:

City/State/Zip:

Phone:

Primary Residence?

Own Rent

Primary Residence?

Own Rent

If "Rent", please complete the landlord info below:

Landlord Name:

Contact:

Street Address:

City/State/Zip:

Phone:

References

Trade Reference 1 Name:

Contact:

Street Address:

City/State/Zip:

Phone:

Account # (if applicable):

Bank Reference Name:

Contact:

Phone:

Account #:

Bank Information

Bank Name:

Contact:

Street Address:

City/State/Zip:

Depository Account #:

Bank Routing Number (9 digits):

Phone:

Additional Information

Total Sales Breakdown

Total Credit Card Sales

Business To Business %:

Business To Consumer %:

Total MUST = 100%

Time Frame For Delivery Of Products/Services

0-7 Days %:

8-14 Days %:

15-30 Days %:

Over 30 Days %:

Total MUST = 100%

Who performs fulfillment??

Direct Vendor

If Vendor, Vendor Name:

Vendor Address:

Vendor Phone:

...

Describe the transaction, from order taking to fulfillment.

...

How will you protect your business from cardholder fraud?

...

If your business does recurring billing, please explain why: