| CARDSERVICE International | 260 Arlington Street
Acton, MA 01720 Phone: (978) 635-9775 Fax: (978) 263-8582 |
| Sales Representative: Jim Greenbaum |
| SERVICES AND MERCHANT INFORMATION | ||||||||||||||||||||||||||||||
| [
] MasterCard/Visa
[
] Check Guarantee
[
] American Express
[
] Diners
[
] EBT Other ____ [ ] ATM/Debit Card [ ] Purchasing Card [ ] Discover/Novus [ ] JCB [ ] Cardsrvice Merchant Club | ||||||||||||||||||||||||||||||
| Legal Name of Business | Merchant's Customer
Service Phone Number ( ) | |||||||||||||||||||||||||||||
| DBA (Doing Business As) | Phone Number ( ) |
Business Fax # ( ) | ||||||||||||||||||||||||||||
| Authorized Business Representative | Relationship/Title | |||||||||||||||||||||||||||||
| Street Address | City | Country | State | ZIP | ||||||||||||||||||||||||||
| Mailing Address | City | Country | State | ZIP | ||||||||||||||||||||||||||
| List Type of Business and Product/Service Sold (be Specific) | Business Hours (circle
a.m. or p.m.) _________ 24 hours
Mon.-Fri. From ______ a.m. p.m. To ______ a.m. p.m. Saturday From ______ a.m. p.m. To ______ a.m. p.m. Sunday From ______ a.m. p.m. To ______ a.m. p.m. | |||||||||||||||||||||||||||||
| Tax ID Number | Business License Number | Age of Business Yrs _____ Mos _____ | ||||||||||||||||||||||||||||
| OWNERSHIP (51% ownership for a corporation, 100% ownership for a partnership or proprietorship, must be accounted for on the application) | ||||||||||||||||||||||||||||||
| [
] Sole Proprietorship
[ ] Partnership
[ ] Public Corporation [ ] Private Corporation [ ] Non-profit Corporation [ ] Limited Liability Company | ||||||||||||||||||||||||||||||
| Principal's Name | Ownership % | Birth Date(mm/dd/yy) |
Title | |||||||||||||||||||||||||||
| Home Phone Social Security # ( ) |
Drivers' License # State/Expiration Date | |||||||||||||||||||||||||||||
| Street Address | City | State | ZIP | [ ] Own [ ] Rent |
How long? Yrs. ____ Mos. ____ | |||||||||||||||||||||||||
| Previous Street Address (if less than 3 years) | City | State | ZIP | [ ] Own [ ] Rent |
How long? Yrs. ____ Mos. ____ | |||||||||||||||||||||||||
| Name of Nearest Relative or Friend Not Residing With Principal | Phone Number ( ) | |||||||||||||||||||||||||||||
| Street Address of Nearest Relative or Friend Not Residing With Principal | City
State
Zip | |||||||||||||||||||||||||||||
| AUTHORIZATION AND AGREEMENT | ||||||||||||||||||||||||||||||
| Merchant authorizes Bank/Cardservice
to investigate and confirm the information contained herein and hereby
certifies that all the information provided, including Merchant's legal
status, is true, correct and complete. Merchant hereby authorizes Bank/Cardservice
to utilize credit bureau reporting agencies and/or its own agents for purposes
of verifying the accuracy of any information provided by Merchant and for
purposes of assessing and monitoring Merchant's credit status. Merchant
authorizes all such credit bureau reporting agencies to release any information
they may have pertaining to Merchant to Bank/Cardservice. This Agreement
may only be modified as approved in writing by authorized officer of the
Bank and the corporate office of Cardservice. No other representative of Bank or Cardservice is authorized to make any verbal or written modification to this Agreement. If Merchant desires to accept American Express â Cards, the undersigned also represents that Merchant has reviewed and agrees to the terms and conditions of the American Express Card Agreement. Additionally, Merchant agrees that all representations and agreements contained in this Cardservice Merchant Application and Agreement shall be deemed to have been made for the benefit of, and may be enforced by, American Express Travel Related Services Company Inc. (also referred to herein as "Amex"), as well as for Cardservice and Bank, and American Express may use all information (including but not limited to consumer credit bureau reports) referred to herein. | ||||||||||||||||||||||||||||||
|
_________________________________________________________ Principal or Corporation Officer Date |
________________________________________________________ Principal or Corporation Officer Date | |||||||||||||||||||||||||||||
[ ] purchase amount on my equipment [ ] Please charge the application fee in the amount of $ ______ I authorize CSI N.E. to charge the about amount to
my credit card
X ____________________________________________________________________ |
| HOME | E-COMMERCE | SAMPLES | STARTUP | WEB SERVICES |