Merchant Services Pre-Application

Shortgrass Web Development

Business Legal Name

DBA Name

Business Address

City

State

ZIP

Contact Name

Business Phone

Business Fax

Email Address

Website Address

Requested Service Start Date

Is this date flexible?

Products/Services Sold

Number of Employees

Federal Tax ID

Month/Year ID Started

Tax Filing Type

Other Tax Filing Type

Tax Exempt?

Total Gross Annual Sales:
Estimated Annual Credit Card Sales:
Estimated Average Credit Card Individual Sale Amount:
Estimated Highest Credit Card Individual Sale Amount:

Signor (must be an officer or controller of a private corp., member LLC, or an individual only of a sole proprietorship)

Signor/Owner Name

Title

% Ownership in Company

Home Address

City

State

ZIP

Home Phone

Social Security Number

Date of Birth

Driver License #

DL State

DL Expires

Deposit Bank (checking only)

Bank Name

Routing Number

Account Number

Phone