Merchant Account Application

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consultation & assessment!

Merchant Account Application

In order to set up your merchant account you will need to click on "Step 1 of 5" below to get started. Our 5 step application will take about 10 minutes to complete.

Please complete as much information as possible. This will ensure we are able to set up your merchant account in a timely manner. Once you complete the secure form below we will send you a merchant agreement for you to sign.

Once you have completed the form below you will need to fax us the following information:

Copy of Owner/Offier's Drivers License

3 months current merchant account processing statements (if applicable)

Proof of existence (Copy of Business License or Non-Profit 501(c)(3) status letter)

A valid Checking Account and Routing Number (Please attach voided check)

Signed Merchant Agreement by Owner/Officer from your organization

Please fax documents above to 213-402-5997 with CC Setup Documents as Subject Line

Donor Depot Sales Representative (First & Last Name): *

Step 2 of 5 - Account Information

Bank Contact:

Depository Bank:

Bank Phone:

(xxx-xxx-xxxx)

ABA Routing Number:

9 digits

DDA Account Number:

Account Type:

Checking

Savings

How are you currently processing transactions (check all that apply)?:

Not currently setup to process Credit or Debit Cards

Virtual Terminal (VT) - Web-based virtual terminal application which performs the processing functions of a physical Point of Sale (POS) processing solution

Mobile Transaction Terminal (MTT) - Combines mobile phone technology with a (POS) terminal

Dial Up Terminal (DUT) - An authorized terminal that (like a telephone) dials the authorization center for validation of transactions

Payment Processing Integrated into Customer Relationship Management Software (CRM) - Process by which organization pushes transactions through a (CRM) software solution to validate transactions (often times a gateway solution such as Authorize.net is used to setup this capability)

Internet Processing - Process by which organizations process transactions online such as an online contribution form, shopping cart, or payment page

Step 3 of 5 - Owner/Officer (s)

Owner First Name:

Owner Last Name:

Owner Title:

Drivers License Number:

DL State:

Home Address:

(No PO Boxes)

City:

State:

Zip Code:

(xxxxx)

Home Phone:

(xxx-xxx-xxxx)

% of Ownership: %

If organization is nonprofit place a 0% in this field

Date of Birth: (01-01-65)

Owner/Officer #2 (Optional)

If organization is non-profit then this section is not required to be completed by a second Owner/Officer.

Owner First Name:

Owner Last Name:

Owner Title:

Drivers License Number:

DL State:

Home Address:

(No PO Boxes)

City:

State:

Zip Code:

(xxxxx)

Home Phone:

(xxx-xxx-xxxx)

% of Ownership: %

If organization is nonprofit place a 0% in this field

Date of Birth: (01-01-65)

Step 4 of 5 - Merchant Processing Information

Monthly Visa/MC Sales: $

Products Sold:

Average Ticket Size: $

Total Monthly Sales: $

(Including cash & checks)

Visa/MC Sales Profile

Total must equal 100%. Place 0% in those fields not generating sales.

Cards Keyed Face-to-Face: %

Cards Keyed Via Internet: %

Cards Keyed Via MOTO (mail/phone/fax): %

Cards Swiped: %

Ever File Bankruptcy?:

Length of Ownership:

Years at Current Location:

Ever had a Merchant Account?:

Yes

Refund Policy

What is your organization's refund policy?:

30 day money back guarantee

30 day exchange-only

Other

If other, please explain.:

Step 5 of 5 - Choose Pricing Plan

Which rate plans/options best meets your needs as an organization (check all that apply)?:

Low Fees Plan - Discount Rate: 2.39% + Transaction Fee: $0.25 + Statement Fee: $8.00 (Low monthly processing volume)

Best Value Plan - Discount Rate: 2.29% + Transaction Fee: $0.25 + Statement Fee: $12.00 (Medium monthly processing volume)

Low Rates Plan - Discount Rate: 2.19% + Transaction Fee: $0.20 + Statement Fee: $15.00 (High monthly processing volume)

ACH/EFT Plan - Transaction Fee: $0.50 cents + Statement Fee: $10.00

Quote - Please provide me a credit card quote (will need to provide current CC monthly volume levels)

Setup Options (Internal Staff Only)

Mobile Transaction Terminal Setup (MTT)

How many (MTT) terminals will you need to purchase?:

How many existing (MTT) terminals will you need merchant ID numbers (MID) changed out?:

Virtual Terminal Setup (VT)

How many (VT) users will we be supporting?:

Dial Up Terminal Setup (DUT)

How many (DUT) terminals will you need to purchase?:

How many existing (DUT) terminals will you need merchant ID numbers (MID) changed out?:

Payment Processing Integration into (CRM) Software

What is the name of the (CRM) software solution you need payment processing integrated into?:

What is the name of the gateway solution you use to integrate into your software?:

What API’s or assistance will your staff offer for integration?:

Internet Processing

What internet processing solutions will you need built?:

Online Contribution Form

Shopping Cart

Payment Page

What internet processing solutions will you need merchant ID numbers (MID) changed out?:

Online Contribution Form

Shopping Cart

Payment Page

Who is the contact assisting us with this project?

Contact Name:

Contact Phone:

(xxx-xxx-xxxx)

Contact Email:

What is the deadline for this solution to be setup?:

Notes:

Merchant Account Application

Main Menu

Gateway

NAME:
EMAIL:
PHONE: