QuickBooks Plug-in and Merchant Account Application

I Need a Merchant Account AND The QuickBooks Plug-in

If you already have a merchant account and just need the Quickbooks Plug-in only, Apply Here Instead.

In order to apply for the QuickBooks Plug-in, a credit card is needed for a one-time setup fee and monthly billing thereafter. In addition, a merchant account application is required too. Please fill in the form below to continue:

Payment Information

Note:*items are required to submit form.

*Credit-Card-Type:

-- Select One -- Visa MasterCard

*Credit Card number:

*CVV number: What's this?

*Expiration:

*Name as shown on Credit Card:

Business Information

*LEGAL Name of Business:

*Industry Type:

-- Select One -- Retail Restaurant Quick Service Restaurant (fast food) Taxi Limo Delivery Internet/Ecommerce Phone/Mail Order Other

*QuickBooks software version:

-- Select One -- QuickBooks Professional (USA Version) 2005-2009 QuickBooks Professional (Canadian Version) 2006-2009 QuickBooks Enterprise Solutions 5.0-9.0 QuickBooks Premier (USA Version) 2005-2009 QuickBooks Premier (Canadian Version) 2006-2009

*Business Profile/Ownership Type:

-- Select One -- Sole Proprietor Corporation PA or PC Partnership LLC Not for Profit Other

*The majority of your business will be:

-- Select One -- Card swiped (face-to-face) Keyed WITH imprint of card Keyed withOUT imprint of card Internet/Ecommerce Phone/Mail Order

*Primary sales method:

-- Select One -- Store front Off premises Trade show Internet/Ecommerce Phone/Mail Order Other

*Contact name:

*Business Owner First Name:

*Business Owner Last Name:

*Title:

-- Select One -- CEO President VP Owner Partner Other

*This person:
Owns the business premises
Leases or Rents premises

*If leasing or renting, provide the Landlord name and phone#:

*Business Address:

*City:

*State:

(Select Location's State) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming Not in U.S.A.

*Zip/Postal Code:

*Federal Tax ID#:

*Business Phone#:

*Business FAX#:

*Bank Name:

*Bank Phone#:

*Checking account number:

*Bank routing number:

*Number of Years in Business:

*Type of goods or services sold (be specific):

*Monthly bank card sales:

*Average ticket amount:

*Email:

Website Address:

Personal Contact Information

*Residence Address:

*City:

*State:

(Select your State) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming Not in U.S.A.

*Zip/Postal Code:

*Years lived at this address:

*Residence (home) phone#:

*Date of Birth:

*Applicant Social Security Number:

*Applicant Driver's License Number:

*State DL is issued in:

*Driver's License Expiration Date:

*Percentage of Equity Ownership:

*Interested in a quote for:

-- Select One -- A RETAIL Merchant Account An E-COMMERCE Merchant Account A MAIL/PHONE Order Merchant Account A Mobile/WIRELESS Merchant Account CHECK Guarantee and/or Conversion other - please specify below Other:

*I will need my Merchant Account activated in:

-- Select One -- Immediately 30-60 days 60 or more days Not sure

Provide any additional comments:

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