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*
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*
Owner Information
Social Security Number for I.D. verification purposes (numbers only)*
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%
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?*
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
FCS Number (if selecting EBT)
Trade References
First reference - Business Name*
First reference - Address*
First reference - Contact*
Second reference - Business Name*
Second reference - Address*
Second reference - Contact*
Second reference - Phone*
Site Information
Site zoned as*
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?*
US Checking accounts only. No savings accounts are accepted.
Name of the bank where you would like your funds deposited*
Equipment Processing Method:
Do you use any third party to store/process/transmit cardholder data ?*
If yes, provide the provider name.
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
*
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
http://www.americanexpress.com/privacy 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.
NOTE: It is okay if your signature appears different than normal
** By Federal Law, All
Information Provided Will Remain Confidential **
To begin accepting credit cards,
click the submit button below