Welcome to National Payment Systems® on

Retail Merchant Account Express Application

[All Information Remains Confidential]

GENERAL INFORMATION:

Your Email Address:


Legal Business Name:


D.B.A.:


Business Address:


 Suite:
City/State/Zip:


State:


Type of Business (Name Product/Service):


Business Hours:


% Mail Order:


% Phone Orders:


% Trade Show:


# of Locs:


Year Started:


Fed Tax ID:


 State Tax ID (If Retail):
Principal Contact:


 Title:
Phone No:


 Fax No:
Est. Card $/Mo:


 Avg. $/Sale:
Type of Business

Sole Prop:


Partnership:


Corp:


State of Incorporation:


Age of Business:


Date Acquired:



OWNER/PRINCIPAL INFORMATION:

President/Owner:


Title:


% Ownership:


S.S.# (Req.):


Residence Address:


City/State/Zip:


I Own:


I Rent:


Since:


Home Phone:


Prev. Address (if less than 3 years):


Date of Birth:


Co-Owner (If Applies):


Title:


% Owned:


S.S.# (Req.):


Residence Address:


City/State/Zip:


Business Location...Type of Building

Commercial:


Residential:


Retail:


Please Rank Your Credit

Excellent:

Fair:

Poor:


Prior Chapter 7, 11, 13?
Yes:

No:

Year:


Type of Processing Equipment (required to process credit card transactions)

PC Software:


 Terminal:
Lease:


 Purchase:


 Reprogram Existing:
BUSINESS REFERENCES

(List Media, Printers, Suppliers, Etc.)

Trade #1:


Phone:


Contact:


Trade #2:


Phone:


Contact:


Trade #3:


Phone:


Contact:


Thank you.
Your privacy is of utmost importance to us. We do not provide any information collected from our site to any third party without your permission. Your application will be processed promptly.

THANK YOU.
NPSGLOBAL WILL RESPOND WITHIN 48 HOURS!

LEGAL NOTICE
© 1995-2009 National Payment Systems®. NPS®, NPSGLOBAL™, NPS® Payment Processing,ClearedCheck™ and National Payment Systems® are trademarks of National Payment Systems Corp. All Rights Reserved. Other product and company names mentioned are trademarks of their respective owners.