Apply for the QuickBooks Payment Processing Plug-in

I Have an Existing Merchant Account. I Just Need The Plugin

If you need a merchant account also, 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. 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

*Current merchant processor:

-- Select One -- TSYS (formally Vital or Visanet) Elavon (formally Nova) First Data (Nashville platform) Global Payments (East platform) Fifth Third (St. Pete or Tandem platform) Concord EFS RBS Worldpay (formally RBS Lynk) Comdata First Tennessee Bank Paymentech (Salem or Tampa) 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

*Contact name:

*Business Owner First Name:

*Business Owner Last Name:

*Title:

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

*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:

*Business Phone#:

*Business FAX#:

*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:

*Residence (home) phone#:

Provide any additional comments:

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