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Merchant Information Request Forms

Old School (print and fax)

Fax: (877) 706-7473

PDF: Merchant Information Request form

Word: Merchant Information Request form

Submit Online:

Business (DBA) (required)

Corporate Legal Name (required)

Business Address (required)

City (required)

State (required)

Zip (required)

Business Phone (required)

Mobile

Fax

Website

Time Zone
 EST CST MST PST

Business Style
 Retail Internet

Business Type

Federal Tax ID (EIN)

Year Started Business

Length of Ownership

Years

Months

Ownership Information

Your Name (required)

Date of Birth (required)

Your Email (required)

Home Phone

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