Austin Credit Card Processing - Get Started Today

Merchant Application

Type of Account Applying For	Credit Card ACH E-check Services

Business Information
D/B/A name
Legal name
Address
City
State Zip
Contact name
Contact Email address
Corporate phone
Corporate fax
Web address
Total # Locations
Ownership:	Proprietorship Partnerhsip Corporation LLC NonProfit
Type of Business	Retail Wholesale Restaurant Lodging Convenience Store Supermarket MO/TO Home Business Trade Fairs Outside Sales/Services Internet Only
Date established
Does this location currently accept Visa/MasterCard?	Yes No
Average Ticket
Size of high ticket
Monthly average volume Or Annual average volume
Sales Method (Total must be 100)	Retail Swiped % Hand Key No Imprint % Hand Key With Imprint & Signature %

Non Bank Card Do you need accounts in addition to Visa/Mastercard, and whether or not you have current accounts.	American Express Do you have a current account? Yes No Discover Do you have a current account? Yes No Diners/Cart Blanche Do you have a current account? Yes No

Site Information	Retail Store Front Office/Warehouse Residential Other:

Owner – Officer Information – Two Are Required
Owner/Officer Name #1
Title
Home Address
City
State Zip
Home Phone
% of ownership

Owner/Officer Name #2
Title
Home Address
City
State Zip
Home Phone
% of ownership

Have principals filed bankruptcy during the past two years?	Yes No

Trade References - Two Are Required
Trade Reference Name #1
Contact
Phone
Account #

Trade Reference Name #2
Contact
Phone
Account #

Please ensure that all information provided is correct and complete prior to submitting this form. Please submit only once. Please note: A hard copy of the merchant processing agreement (MPA) must be submitted. A follow up call will be made to you within 24 hours to collect further information. In order to protect your identity we do not ask for you to transmit over the internet any confidential personal or business information. Once that occurs we will email you a completed application for your review and approval. This application will require your authorization and will be sent back to us for approval. Thank you and please understand that submittal of this information by no means obligates you to anything and if you have any questions please call or email us first.

In the mean time, please email us for more information.

Privacy Policy - Copyright ©2009 Jacor Inc, All Rights Reserved. Jacor Inc dba/Cocard is a registered agent of EDC Processing Services, a member of CoCard Marketing Group, LLC is a registered ISO/MSP of Wells Fargo Bank, N.A., Walnut Creek , CA, Chase Paymentech Solutions, LLC, and Columbus Bank & Trust Company, Columbus, Georgia. American Express requires separate approval. Powered by Verritech.