ISO INFORMATION - Valued Merchant Services



MERCHANT PROCESSING GENERAL APPLICATION

|BUSINESS INFORMATION |

|Corporate Information |State/Country Filed: |

| Sole Prop Partnership Public Corp. Private Corp. LLC | |

|Legal Name: |Business Telephone: |Business Fax: |

| | | |

|Business Name (DBA): |Website Address: |

| | |

|Contact Name: |Contact E-Mail: |

| | |

|Cardholder Descriptor: (21 characters max.) |Business Start Date : |Federal Tax ID: |

|      | |      |

|Description of Products/Services: |

| |

|OWNERS/PARTNERS/OFFICERS (OWNERSHIP MUST TOTAL 50%) |

|Name: |Title: |Equity / Ownership%: |

| |

|Date of Birth: |Driver’s License & State / Passport # |Social Security # |

| | |      |

|Home Address: |City / State / Zip Code |Home Telephone: |

| | | |

|Name: |Title: |Equity / Ownership%: |

| |President | |

|Date of Birth: |Driver’s License & State / Passport # |Social Security # |

| | | |

|Home Address: |City / State / Zip Code |Home Telephone: |

| | | |

|MERCHANT PROFILE |

|Which do you currently accept? |Name of previous processor: |Ever been listed on the Terminated Merchant File? |

|(check all that apply) | | |

| Visa MasterCard Discover |       | No Yes, provide date       |

|American Express None | | |

|Equipment Type: |Accepted Currencies: |Merchant Account Type: |

| Gateway: New Account Existing | USD BPD | Domestic International |

|Terminal Make & Model:       |EUR Other: CND (Canadian) | |

|Describe your refunding policy: |Seasonality: |

|      | J F M A M J J |

| |A S O N D 1 none |

|Processing Volume for Visa/MC/Discover: |Where are Sales Transacted? |How are Sales Transacted? |

| Average Monthly Volume | Store Front/ face- face    % | Electronic Data Capture/Swipe % |

|Average Ticket |Internet % |Manual Entry, no card present    % |

|Highest Avg. Ticket |MOTO    % |Voice Authorization & Capture    % |

| |Other       % |Other          % |

| |Total Must Equal 100% |Total Must Equal 100% |

|MOTO/ CARD NOT PRESENT / B2B Information |

| What percentage of total sales represent Business to Business: B2B    % B2C    % = 100% (total sales) |

|What percentage of bankcard sales represent Business to Business: B2B    % B2C    % = 100% (total sales) |

|What is the time from transaction to deliver? (% of orders delivered in days) 0-7    % 8-14    % 15-30    % 30+    % = 100% |

|Visa/MasterCard/Disc sales are deposited on: Date of Order Date of Delivery Other       |

This application will be used solely for the purpose of pre-approval. Please include the following 3 months processing statements, 3 months bank statements, copy of driver’s license, current P&L, 2 years tax returns, Articles of Incorporation. Once this application is completed, please send via email to sales@ or via fax to 877-885-1740.

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