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Please complete the following application to apply for a First Nevada Merchant Account

Business Name(s) and Profile
 
Legal Name
Billing Address
City
State
Zip
 
Doing Business As (DBA)
Location Address
City
State
Zip
 
Merchant Contact
Corporate Phone Number
ie: 000-000-0000
Fax Number
ie: 000-000-0000
Location Phone Number
ie: 000-000-0000
Federal Tax ID#
9 digit number
Products Sold
Largest Sale Processed
Date Business Started
Does location currently accept Visa/MC
Current Processor
Visa/MC Average Ticket
Visa/MC Monthly Sales Volume
Ownership
Type of Business
 
Sales Method - Very Important that this profile be correct. It must add up to 100%
 
Retail Swiped
%
Hand Key/No Imprint
%
Hand Keyed w/Imprint & Signature
%
How would you rate your credit from
1 to 10 with 10 being the best
 
Personal Data - Owner/Officer
 
Mr/Mrs Name & Title
Social Security Number
ie: 000-00-0000
Home Phone Number
ie: 000-000-0000
Home Address
Birth Date
City
State
Zip
% of Ownership
Drivers License Number
State
 
Mr/Mrs Name & Title
Social Security Number
ie: 000-00-0000
Home Phone Number
ie: 000-000-0000
Home Address
Birth Date
City
State
Zip
% of Ownership
Drivers License Number
State
 
Business References
 
Trade Reference (Supplier) Name
Contact
Phone Number
ie: 000-000-0000
 
Trade Reference (Supplier) Name
Contact
Phone Number
ie: 000-000-0000
 
Bank Name - ACH Bank
Account Number
Phone Number
ie: 000-000-0000
 
All of information entered above is correct and accurate
Please select Yes or No