REV19 Merchant Application Form Please enable JavaScript in your browser to complete this form.Merchant Name (DBA or Trade Name) *Location Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCorporate/Legal Name (if different)Is your Corporate/Billing address the same as your location address? *YesNoCorporate Address (if different)Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeContact Name *FirstMiddleLastContact Email *Contact Phone Number *Fax NumberDoes this location currently accept payment cards? *YesNoHave you ever been terminated from accepting payment cards from any payment network for this business or any other business? *YesNoBusiness InformationFederal Tax ID Number *Type of Business *Individual/Sole ProprietorPartnershipCorporationLimited Liability Corporation (LLC)GovernmentNon-Profit (501c3)PrivatePublicly Traded-Stock SymbolNature of Business *RetailRetail w/TipMail/Phone OrderInternetRestaurantFast FoodLodgingQSRConveniencePublic SectorPetroleumUtilityHealth CareOtherDescribe the Products or Services being sold *Date Business Established *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Is your business seasonal? *YesNoWhat months are you open?Website / URL *If you don't have a website, enter NONE (Facebook pages count!)Method of AcceptancePercent of Swiped Transactions *Percent of Keyed Transactions *Percent of E-Commerce/Internet Transactions *Percent of Mail Order/Telephone Order Transactions *Totals must equal 100%Do you currently use processing software or a terminal? *SoftwareTerminalNot Currently ProcessingI'm not surePlease provide the make and model of each device currently in usePlease provide the make and model of each device currently in useFinancialsPlease estimate your volume if you haven't processed before. If you have, please use an average over a few months to estimate your totals. Monthly Credit Card Volume *Average Ticket *Monthly American Express Volume *High Ticket *Do you use an independent servicer that stores, maintains or transmits cardholder information? *YesNoPlease provide the name of your Third Party Servicer and Contact InformationDo you use a fulfillment warehouse to fill or store product? *YesNoPlease provide the name and contact information of the company assisting you with product fullfillmentHave you ever filed for Bankruptcy, Business or Personal? *YesNoIs your bankruptcy open or closed?Open BankruptcyClosed and ResolvedIf your bankruptcy is still open, please provide current status detailsPrincipals/Beneficial OwnerPrincipal/Owner Name *FirstMiddleLastTitle *Percent of Ownership *If less than 50%, two signors will be requiredHome Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDate of Birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Social Security Number (SSN) *Phone Number *Email *Drivers License Number *Please upload a copy of your drivers license belowDrivers License State *Site InspectionDo you own or rent your place of business? *OwnRentPlease provide us with your landlords contact informationWhat type of building does your business reside in?Shopping CenterOffice BuildingIndustrial BuildingResidenceWhat type of zone is your building located in?CommercialIndustrialResidentialHow many square feet is your building?0-500501-25002501-50005001-10000+Bank Account InformationA business checking account is requiredBank Name *Routing Number *Checking Account Number *Proof of BusinessPlease upload as many supporting documents as available. If you need time to prepare them, submit this form now and send your documents when they're ready to sales@capitalbankcardne.comDrivers License Click or drag a file to this area to upload. Please upload a copy of the front of your drivers license. A picture or scanned copy is required.Voided Blank Check Click or drag a file to this area to upload. Please upload a copy of a voided blank check. The business name, contact, routing and account number must be visible.Articles of Incorporation / 501c3 / State Permits Click or drag a file to this area to upload. Please provide a copy of your Articles of Incorporation, non-profit tax documents (if applicable), and any licenses or permits as supporting documentation.Thank you for taking the time to submit all your business information! Please understand a Merchant Account is similar to an advanced line of credit. There is underwriting involved based on the information you've provided. It is important that this information is as accurate as possible. If you have any questions, feel free to leave a note in the space below or call our office.EmailSubmit