CYBERAUTHORIZE



CYBERAUTHORIZE® Merchant Services is a leading National Merchant Service Provider and a Member of the Better Business Bureau.


Merchants may also mail or fax their merchant account application to our sales office.



Apply Now for a CYBERAUTHORIZE® Merchant Account. Rates starting at 1.49%
To get started simply complete and submit our secure merchant account application. A Customer Care representative will contact you directly to issue your business merchant account. CONTACT OUR OFFICE, TOLL FREE, WITH QUESTIONS AT 1-800-216-4886


Business Information
Legal Business Name:
DBA (Doing Business As):
Business Address:
City:
State:
(e.g. NY, NJ. CA, FL)
Zipcode:
Number of Years Established:
(0-99)
Business Telephone:
Business Fax:
Federal Tax Identification Number:
How is your business organized:
What products or services do you sell (be specific)?
Do you have prior experience in a similiar business?
If so, how many years of experience do you have?
(0-99)
Email Address:
Website Address (if applicable):
http://www.
Have you or the business ever been party to any claims or lawsuits?
If yes, please explain:
Have you ever filed for bankruptcy?
Banking Information
Bank Name:
Account Number:
Routing Number:
Personal Information
(only Principle #1 information is required if Principle #1 owns 51% or more of the business)
Principle #1 Name:
Title:
Ownership %:
(1-100 )
Home Address:
City:
State:
(e.g. NY, NJ. CA, FL)
Zipcode:
Telephone:
Number of years at current address:
(0-99)
SSN:
Drivers License No:
Drivers License State:

(e.g. NY, NJ. CA, FL)
Drivers License Expiration Date:
(mm/dd/yy)
Date of Birth:
(mm/dd/yy)
Previous address if current address is less than 2 years old:
City:
State:
(e.g. NY, NJ. CA, FL)
Zipcode:
Number of years at previous address:
(1-99)
Principle #2 Information
(Principle #2 information is not required if Principle #1 owns 51% or more of the business)
Principle #2 Name:
Title:
Ownership %:
(1-100)
Home Address:
City:
State:
(e.g. NY, NJ. CA, FL)
Zipcode:
Telephone:
Number of Years at current address:
(0-99
SSN:
Drivers License No:
Drivers License State:

(e.g. NY, NJ. CA, FL)
Drivers License Expiration Date:
(mm/dd/yy)
Date of Birth:
(mm/dd/yy)
Previous address if current address is less than 2 years old:
City:
State:
(e.g. NY, NJ. CA, FL)
Zipcode:
Number of years at previous address:
(1-99)
Marketing Method
(let us know how you plan to use your merchant account)
Retail%:
 (0-100)
Mail Order/Telephone Order %:
(0-100)
Trade Show%:
(0-100)
Kiosk %:
(0-100)
Internet %:
(0-100)
Other %:
(0-100)
Do you currently accept Visa/Mastercard:
If yes, who is your current processor?
Anticipated Monthly Credit Card Volume in $:

(do not add dollar sign)
Average Sales in $:

(do not add dollar sign)
Highest Ticket Size in $:

(do not add dollar sign)
Year business was established:
(e.g. 2006)
Has any of the principles of this organization ever have a bankcard relationship terminated?
If yes, please explain why:
Is there signage at the physical location of the business?
Where is the physical location of the business:
Comments/Notes
(additional merchant comments):
Requested Service
(We provide a merchant account with every payment solution)
Service Requested:
Optional Services:
Click button to Start Accepting All Major Credit Cards for your Business!
CONTACT OUR OFFICE, TOLL FREE, WITH QUESTIONS AT 1-800-216-4886