Legal Name of Business   DBA (Doing Business As) (only 22 characters including spaces)   Street Address (Physical address—No P.O. Boxes)   City State Zip Business Phone Number   Age of Business Years Months Merchant Email Address       Principal Owner’s Name Ownership %   Title Home Telephone   List Type of Business/Products/Services Sold and How (Be specific)     Authorized Business Rep       Business Type:   Proprietorship Private Corp       Public Corp Government (Federal/state/local)   Medical or Legal Corporation Partnership   International Organization Limited Liability Co. Non-Profit Corp. Associations/Estates and Trusts     Tax-Exempt Org. (501C)         Combined Estimated Monthly Volume Typical Ticket/Sales Amount Estimated Highest Ticket/Sales Amount         Method of Processing - Select all that apply   Face to Face Mail Order (MO) Telephone Order (TO) Internet Swiped       Marketing Method   Swiped Keyed         1. Are you now processing or have you ever processed MasterCard/Visa/Discover Network/American Express? Yes No   If "YES" please enter the name of the processor:      2. Have you ever had a payment card processing relationship terminated? Yes No   3. Do you use any third party to store, process or transmit cardholder data? Yes No       PLEASE MARK ALL CARDS YOU WISH TO ACCEPT IN YOUR BUSINESS   Visa Credit Visa Non-PIN Debit     MasterCard Credit MasterCard Non-PIN Debit     Discover Network American Express Transactions