Apply For A Merchant Account

Fill out the form below to have your merchant account setup. Once it's setup you can start processing immediately.

General Information

Name of Account ("DBA" Doing Business As - appears on Receipts)
Location Address
Location City
Location State
Location Zip
Click Here only if Billing Address different from Location Address
Location Phone Number
Corporate Office Phone # (if different from Location)
Website Address
Corporate Email Address
Legal Tax Filing Name
Taxpayer ID (Corporate Federal ID "FEIN #")
Primary Client Contact(s) Name

 

Business Details

% of Business Swiped (versus Keyed versus Internet)
Describe Goods/Services sold
When are products/services delivered?
Average Transaction Size (Approx)
Maximum Transaction Size (For Now)
Estimated Annual $ CC Volume
Refund Policy
If Policy Other, Which (Max 75 Characters):
Type of Ownership
Years in Business
# of Locations

 

Principal Information

Principal Owner - First Name
Principal Owner - Last Name
Principal Title (Owner, President, Co-Owner, LLC Partner, Exec Director, Other)
Principal Birthdate (mm/dd/yyyy)
Principal SSN
Principal Driver's License # (not required if including Driver's License)
Principal Driver's License State
Home-based Business?
Home Street Address of Principal
Home City of Principal
Home State of Principal
Home Zip of Principal
Principal Own/Rent Home (and # of years if home-based business)
# of Years at Home (if home-based business)
% of Company Ownership
Any Prior Bankruptcies (Yes/No)

 

Checking Account Information

Routing Number
Account Number

 

Additional Information

Do you currently accept American Express?
Existing Amex Merchant # (if applicable)
How did you hear about Freedom Merchants?
if Other, please specify:
How much is:
Answer:
Thank You, we have received your submission.
We will be in touch shortly
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