Business Profile

Credit Card Processing Service

(Information for pre-qualification purposes only and not a guarantee of acceptance.)

The personal information you supply will be used for the purpose of qualifying you as a merchant account by Mercury Payment Systems. This information is held in the strictest confidence and is never sold, rented, or shared with any other business or third party.

Please fill out the form below. Fields with (*) are required.

Business Profile

DBA Business

* Business/DBA Name
 
* Street Address
 
City
State
* Zip
 
* Phone
 
Fax
Primary DBA Contact
 
Statement Address
Use DBA

Legal Business

Same as DBA address
* Legal Business Name
 
* Street Address
 
City
State
* Zip
 
Phone
Fax
* Primary Legal Contact
 
Statement Address
Use Legal

Business

* Owner/Officer Name
Email Address
Home Phone
Home Address
Home City
State
* Zip
Years at this Address
  Rent Own

Business Type

                    Sole Proprietorship Partnership Corporation LLC Tax Exempt
* Product or Service Sold
 
Federal Tax ID
Annual Visa/MC/Discover Sales
Years Business Owned
Total Number of Locations
Projected Processing Date

Application

                   Application for the following credit cards (select all that apply).
                    Visa/MasterCard/Discover American Express EBT Debit (with pinpad) JCB
FNS#
(7 digits)
Existing Discover Merchant Number
(15 digits)
Existing AMEX Merchant Number
(10 digits)
   

Receiving Application

* New or Existing Business
New    Existing
* Type of Merchant

Existing Service

                   Would you like the application Faxed or E-mailed?
Fax Number or Email Address
What is the best way to contact you?
DBA Phone Cell Phone Email
Please add comments or questions here

Your Dealer’s Information

Contact Information

Dealership Name
 
Name/Primary Contact
Phone

Verification

Please fax a voided pre-printed business check to 970-385-3436

(The legal business name and or DBA name that is printed on the bank check must match this business profile exactly)

  

 
Mercury Payment Systems is a registered ISO and MSP of HSBC Bank, USA, National Association, Buffalo, NY.
Copyright © Mercury Payment Systems, LLC. 2001-2010. All rights reserved.