merchant accounts

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Please fill out this form as completely as possible. However, if there is any information that you do not have available or any question you do not understand, simply leave that section blank, and our staff will help you to obtain the missing information when we process your application. We are here to make sure that your merchant account application process is prompt and pleasant.

Remember that all of this information will be kept completely confidential. Charge.Com will not share any of your contact information with anyone under any circumstances.

Please make sure that all names and addresses are spelled correctly. This is exactly how they will appear on your merchant account file.

Owner's Name: Mr. Ms. Dr.

First: Middle Initial: Last:

Type of Ownership:

Ownership Percentage: %

Is This a Home-Based Business?

Date of Birth (MM/DD/YY): / /

Contact Name, If Different:

Legal Name of Business:

Doing Business as (DBA), If Applicable:

Location of Business (No P.O. Boxes. If Home-Based, Enter Home Address):

Suite or Apartment # If Applicable

City: State:

ZIP:

Country: United States Other

If Outside the USA, Please Enter Country Here:

If home address is the same as business address, click this box:

Home Address:

Suite or Apartment # If Applicable

City:

State:

ZIP:

Country:

Home Phone Number: ( ) -

Business Phone Number: ( ) -

Best Phone Number To Reach Applicant: ( ) -

Fax Number: ( ) -

Your Email Address:

Your World Wide Web Address (If Applicable):

What Product or Service are you Selling? (i.e. I sell flowers):

Estimated Average Individual Credit Card Sale Amount: $

Estimated Total Monthly Credit Card Sales: $

Please, If You Remember, Where Did You Hear About Charge.Com?

Please Feel Free to Send Us Any Comments You May Have:

** By Federal Law, All Information Provided Will Remain Confidential **

To become a credit card merchant, click the submit button:

Charge.Com, Inc. is a registered ISO/MSP for FDIC insured Wells Fargo Bank, Walnut Creek, CA.

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