Card Processing Services Form

Merchant Application

Required Information

• DBA/Outlet Name
• Employer Identification Number or Social Security Number
• Physical Address
• City
• State
• Zip
• Phone Number
• Business Name
• Federal Tax ID #

Additional Information

• Mailing Address
  • (Mailing) City
  • (Mailing) State
  • (Mailing) Zip
  • (Mailing) Phone
  • (Mailing) Fax
• Business Website
• Year Business Established
• Type of Goods or Services Sold

Market Type

• Retail
• Supermarket
• Restaurant
• E-Commerce
• Health Care
• Other
• Quick Serve
• Salon/SPA

Personal Information

• First Name
• Last Name
• Title
• Ownership %
• Date of Birth
• Social Security #
• Residential Address
• Full Name

Confirmation

[Submit](/content/graine-opportunity# ""/index.html)