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Electronic Merchant Application

Business Information

Processor Name *

Legal Business Name *

Legal Business Address *

Legal Business Address City *

Legal Business Address State *

Legal Business Address Zip Code *

Number of Employees *

Number of Locations *

DBA Name *

DBA Street Address *

DBA State *

DBA City *

DBA Zip Code *

Business Phone Number *

Business Fax Number

Business Start Date *

Mailing Address *

Business Website *

Business Type / Category *

Description of Products/Services *

W-9 Information

EIN / TAX ID # *

Business Ownership Type *

Banking Information

Bank Name (For Deposits) *

Routing Number *

Bank Account Number *

Owner Information

Owner Name *

Owner Title *

Owner Home Address *

Owner Address City *

Owner Address State *

Owner Address Zip Code *

Owner Date of Birth *

Owner Social Security Number *

Owner Home Phone Number *

Owner Mobile Phone Number *

Percentage of Ownership *

Pricing Information

Keap / Infusionsoft Users will use Authorize.net Integration

Processing Rate on All Gross Sales Volume: 2.75%

Transaction / Authorization Fee: $0.25c

* All interchange fees, assessment fees, monthly/annual fees, authorize.net fees will be suppressed

Account Information

Auto Close Time

Agent Name *

Agent Phone Number *

Assoc / Partner Name

Monthly Sales Volume *

Average Ticket Size *

Highest Ticket Size *

Current Processor

Merchant Industry *

Sales Process *

Instruction

Upon submission this information will be used to apply for a merchant account with

Valued Merchant Services and/or one of our partners.

You will receive a copy of this application by email that requires electronic signature prior to approval. You may also receive requests by email for any supporting documentation required by underwriting.

Please email a voided

business check or bank letter to applications@valuedmerchants.com prior to clicking submit below.

If you have questions about this submission, please contact us at

1-800-531-8575 x 0 or 1-208-569-4289

Keap Apply

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