Merchant Services Application

Business Profile for Merchant Services,(Information for application purposes only and is not a guarantee of acceptance) Please Note: The personal information you supply will be used only for the purpose of qualifying you for a merchant account by VITAPAY. This information is held in the strictest confidence and is never sold, rented, or shared with any other business or third party.

Business/DBA Name:

Legal Business Name:

Business Address:

City:

State

Zip

Main Business Contact Name

*Phone Number

Fax Number

*Email

Website:

*Date of Business Established

*Primary Owner/Officer Name:

*Primary Owners Social Security Number

*Date of Birth

*Primary Owners Mobile Phone Number

Residential Address

City

State

Zip Code

Years at this address:

Own or Rent:

Own

Rent

Average Ticket $:

Federal Tax ID #:

Product/Services Sold

Annual Visa/MC/Discover Sales $

Total number of locations:

Years Business Owned

Surrounding Area:

Commercial

Residential

Industrial

Is the Premises:

Leased

Owner

Anticipated Date to begin processing:

Application for the following card services:

Visa/MasterCard/Discover

American Express

PIN-Based Debit

EBT

What email or fax number would you like us to send your application to?

What is the best way to contact you?

Business Phone

Cell Phone

Upoad Picture of Business Voided Check for Deposits

Upload Picture of Owners Drivers Licenses or ID

Upload Business Certificate with EIN # and Business Address

**This is not the final step in the process. VITAPAY will take this info and send an application to you for your review. Your processing account can be set up a few days after you return your signed official application.

Referral By:Optional