CardMax Payments – Online Application

Legal Business Name (As registered with IRS)*

Doing Business As (Appears on Cardholder statements)*

Business Owner *

First

Last

Business Phone*

Customer Service Phone*

Fax

E-mail*

Federal Tax ID

Location Address:*

Street AddressCityState / Province / RegionPostal / Zip Code

Billing Address:*

Street AddressCityState / Province / RegionPostal / Zip Code

Years in Business*

State of Incorporation*

Do you currently process Bankcards?

Yes-(3 most recent statements required)

No

Has this merchant or any principals ever had a merchant relationship terminated?

Yes

No

URL(S)

Products/Services Sold

Do you use a Fulfillment House

Yes

No

Publicly Traded Company?

Yes

No

Principal 1 Name*

First

Last

Position/Title*

Date of Birth*

Drivers License State of Issue

Home Address:*

Street AddressCityState / Province / RegionPostal / Zip Code

Is address rent or owned property?*

Rent

Owned

Home Phone:*

Area Code

-

Phone Number

E-mail:*

Relative Not Living With You

Relative Phone #:

Area Code

-

Phone Number

Principal 2 Name

First

Last

Position/Title(2)

Date of Birth(2)

Drivers License State of Issue(2)

Home Address:(2)

Street AddressCityState / Province / RegionPostal / Zip Code

Is address rent or owned property?(2)

Rent

Owned

Home Phone:(2)

Area Code

-

Phone Number

E-mail:(2)

Relative Not Living With You(2)

Relative Phone #:(2)

Area Code

-

Phone Number

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CardMax Payments Online Application