Business Information
New/Existing Merchant?
Sales Agent Name
Sales Agent ID
Legal Business Name
MID Number
DBA
Billing Address
Zip
City
State
Contact Name
Contact Email Address
Business Address
Zip
City
State
Business Phone
Customer Service Phone
Email
Fax
Website
Entity Type
If Other
Publicly Traded Company?
Symbol
DUNS#
Business Start Date
State of Formation
Years in Business
Months
Locations
Federal Tax ID
Confirm Tax ID
Mail Chargebacks to:
Attention to:
Corporate Address
Zip
City
State
Goods/Services Sold
Products Are Delivered
Owner
Owner 1
First Name
Last Name
Title
Ownership %
Home Address
City
State
Zip
Property is:
Years
Home Phone
Mobile
Social Security Number
Confirm SSN
DL Number
DL State
Date of Birth
Owner 2
First Name
Last Name
Title
Ownership %
Home Address
City
State
Zip
Property is:
Years
Home Phone
Mobile
Social Security Number
Confirm SSN
DL Number
DL State
Date of Birth
Financial Profile
Bank Name
Bank Phone Number
Routing #
DDA #
Confirm DDA #
Credit Cards Swiped %
Card Present (Keyed)%
Mail / Phone Order%
E-Commerce%
Merchant Type
If Other
Products & Services Sold
SIC Code
Prior Bankruptcy
Average Ticket $
High Ticket $
Gross Annual Sales $
Total Monthly Volume $
Annual Visa/MC Volume $
Annual Discover Volume $
Annual Amex Volume $
Accept Credit Cards?
If Yes, With Whom?
Next Day Funding
Seasonal Merchant
Months Active
Jan    Feb    Mar    Apr    
May    Jun    Jul    Aug    
Sep    Oct    Nov    Dec    
Has the merchant or any of the Principals ever had a merchant relationship terminated?
Comments
Site Survey
Type of Building
Business Premises Are:
Square Footage
Is inventory consistent with the described business?
Inspected By
Inspector’s Comments
Questionnaire
Advertisement
Ordering Process
Product Delivery
Refund Policy
Fulfillment House used?
If Yes, Which Service?
Phone
Does merchant present minimal risk of engaging in Internet gambling?
Security Information
Is account data stored electronically?
If yes, indicate which data is stored:
Card Numbers
Expiration Date
CVV2/CVC2
Cardholder Name
Cardholder Address/Zip
Magnetic Stripe Data
Is Merchant PCI DSS compliant?
Was Merchant subject to any ongoing or previous compromise investigations?
Using a Shopping Cart Service?
If Yes, Which Service?
Utilizing a Hosting Provider?
If Yes, Which Provider?