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Carlton Card & Check Services, Inc.
p. 8885688458

Merchant Application and Agreement

Please ensure the information you provide below is accurate and note that required fields are marked with an asterisk  (*)

Note:Failure to provide accurate information may result in a withholding of merchant funding per IRS regulations.  You may refer to section 7 and 19 within the Terms and Conditions link provided at the bottom of this application for further information.

Business Information
Legal name of your business as it appears on your income tax return*
DBA name*
Business street address*
Business suite number
Business zip code*
Business city*
Business state*
Business phone*
Business website
Business email*
Prior Security Breach?*
(If yes, please include your latest proof of PCI DSS compliance.)
Federal Tax ID number of your business as it appears on your income tax return - sole proprietors use Social Security Number (numbers only)*
Tax Type*
Years of ownership*

Owner Information
First name*
Last name*
Social Security Number for I.D. verification purposes (numbers only)*
Phone number*
Ownership percentage*
Street address*
Apartment number
Zip code*
Date of birth*

Business Profile
Type of ownership*
Describe products sold (i.e. I sell flowers)*
Business Type*(Choose an industry type that most closely relates to your business)
Do you use drop-shippers or order fulfillment companies to ship products?*
    List the name(s) of drop shippers used
Delivery methods*
Card charging policies*
Return and refund policies*
Total monthly credit card sales (estimated)*
Average individual credit card sale amount (estimated)*
How are products sold*
Location type*
Recurring billing frequency*
  Please provide a breakdown of how credit card orders will be received. Please use best estimates. Total must equal 100%
Mail or telephone*
Face-to-face where card is swiped through a terminal*
Face-to-face where card is not swiped but is imprinted/keyed*
Are you now processing or have you ever processed Discover®, MasterCard and/or Visa?
    If yes, name of processor(s)
Have you ever had a credit card relationship terminated?
    If yes, provide explanation
Does your system store credit card data?*
Are you PCI compliant?*
  Select American Express and Debit Options
Accept American Express Transactions?
    American Express Estimated Charge Volume
* Required if Accept Amex selected
    American Express OnePoint® Discount Rate:
    American Express OnePoint® Per Transaction Fee:
    American Express OnePoint® Prepaid Discount Rate:
    American Express OnePoint® Prepaid Per Transaction Fee:
Accept Debit Transactions
Accept EBT Transactions
  FCS Number (if selecting EBT)

Trade References
First reference - Business Name*
First reference - Address*
First reference - Contact*
First reference - Phone*
Second reference - Business Name*
Second reference - Address*
Second reference - Contact*
Second reference - Phone*

Site Information
Site zoned as*
Square footage*
Inventory consistent with business type*
    Explanation (if inventory is not consistent)*

Security Questions
Enter the first 6 digits of any of your payment cards*
Have you had any federal or state tax liens within the past 5 years?*
Do you have a mortgage loan?*
With what bank is your mortgage loan?*
What was the initial mortgage loan amount?*

Banking Information
  US Checking accounts only. No savings accounts are accepted.

Name of the bank where you would like your funds deposited*
Name on bank account*
Routing/Transit Number*
Account number*

Rates and Fees
  Discover / Visa / MasterCard Services and Rates
Disc/MC/VS Discount Rate 1.75% + $0.00  
Disc/MC/VS Check Card Rate 1.32% + $0.00  
  Fee Amount Start Date
Disc/VS/MC Transaction Fee $0.20 Per Item  
Non-Bankcard Transaction Fee $0.20 Per Item  
Batch Fee $0.20 Per Batch  
Voice Authorization Fee $0.95 Per Call  
Statement Fee $5.00 Per Month  
Vimas Online Service $0.00 Per Month  
Monthly Minimum $0.00 Per Month May 2021
Gateway Access Fee $0.00 Per Month  
EBT Statement Fee $0.00 Per Month  
Government Compliance Fee $3.00 Per Month  
TIN Mismatch Fee $3.00 Until Validated  
Annual Fee $0.00 Per Year May 2022
AVS Surcharge $0.05 Per Item  
Chargeback Fee $25.00 Per Item  
ACH Reject Fee $25.00 Per Item  
Retrieval Fee $5.00 Per Item  
Early Termination Fee $0.00 One Time  
EBT Transaction Fee $0.00 Per Item  
Debit Surcharge Amount $0.00 Per Item  
Debit Transaction Fee plus Network Fees $0.20 Per Item  

Equipment Processing Method:
Do you use any third party to store/process/transmit cardholder data ?*
If yes, provide the provider name.
Third party* (If Yes)
Do you use any third party to store/process/transmit cardholder data ?*
If yes, for software or VAR users, by checking yes the Merchant certifies that is has used a certified Qualified Integrator or Reseller (QIR) to install or re-program Merchant’s software systems. Notwithstanding Merchant’s use of a QIR as described herein above, Merchant acknowledges that it is, and shall remain, fully responsible for compliance with PCI- DSS standards at all times in accordance with the Program Terms and Conditions (Program Guide).
Name of QIR Used* (If Yes)

Terms and Conditions and Disclosure Page
   * I hereby accept fees and account rates above and authorize Priority Payment Systems, LLC to initiate credits and debits to my settlement account. I have read the Terms and Conditions and Disclosure Page.
     No, I do not agree to the fees and rates and do not authorize Priority Payment Systems, LLC to initiate credits and debits to my settlement account. Please note, by selecting NO your application will not be submitted.
  All merchants are enabled for Visa, MasterCard and Discover® acceptance

* By checking this box, I represent that I have read and am authorized to sign and submit this application for the above entity, which agrees to be bound by the American Express® Card Acceptance Agreement (“Agreement”), and that all information provided herein is true, complete and accurate.

I authorize Priority Payment Systems, LLC. and American Express Travel Related Services Company, Inc. (“AXP”) and AXP’s agents and Affiliates to verify the information in this application and receive and exchange information about me personally, including by requesting reports from consumer reporting agencies from time to time, and disclose such information to their agent, subcontractors, Affiliates and other parties for any purpose permitted by law. I authorize and direct Priority Payment Systems, LLC. and AXP and AXP’s agents and Affiliates to inform me directly, or inform the entity above, about the contents of reports about me that they have requested from consumer reporting agencies. Such information will include the name and address of the agency furnishing the report. I also authorize AXP to use the report on me from consumer reporting agencies for marketing and administrative purposes. I am able to read and understand the English language. Please read the American Express Privacy Statement at to learn more about how American Express protects your privacy and how American Express uses your information.  I understand that I may opt out of marketing communications by visiting this website or contacting American Express at 1-800-528-5200.

Using your mouse and left clicking in the signature box below, please sign your name .

Your Signature Here
A valid signature requires at least 5 points.

Click Submit & Finish below when you are ready to
(1) confirm your signature,
(2) confirm you have corrected all errors, and
(3) submit all electronically signed documents.
To begin accepting credit cards, click the submit button: