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Merchant account prequalification application

Please fill out this form if you are currently seeking a merchant account. If you have any questions regarding this service, please contact us.

PLEASE NOTE:
This form will assist your merchant services representative in setting up your merchant account. Please fill out this form completely and click the submit button.You will be contacted shortly thereafter

BUSINESS PROFILE

First name:
Last Name:
Legal / Corporate Name:
DBA Name:
Business Street:
City:
State:
ZIP Code:
Country:
Business Phone:
Business Fax:
Fed. Tax ID#:
Primary Website:
Email:
Years in Business:
Have you processed credit cards before?
Are you interested in processing checks?
Have you had a merchant account terminated?
Reason for termination:
Type of product or service sold:
Expected Monthly Volume:
Average ticket item cost:
Who referred you to InterCharge?
If you are currently accepting credit cards and/or online checks for your web site, please answer the following:
Who is your current processor?
Current monthly volume?
Current monthly chargeback rate?