PayNet - Application

What is the legal name of your business?
If your business goes by another name, what is it? (This name will appear on cardholder statements.)
Who is the primary contact person for this account?
Business type
Federal Tax ID#
For how many years as it been under current ownership?
Has the Company or any principal or owner ever filed for Bankruptcy?
If you are not currently open for business, when do you anticipate beginning operations?
What is the physical address of the business? (No P.O. boxes or mail drops.)
City, State, Zip
Country
The business premises is best described as
Is the premise(s) owned or leased?
Phone (at physical location)	Ext.
If you have another phone number (for example, a headquarters location, cell phone or pager), what is it?
Fax
Customer service phone? (Toll-free number preferred, since this number will appear on cardholder statements.)
E-mail address for primary contact
If you have a website, please provide URL
Brief description of your products and/or services
If you currently accept credit cards, who is your processor?
How many years have you been with your current processor?
Please estimate your annual Visa/Mastercard sales volume	$ .00
Please estimate your average Visa/Mastercard sale amount	$ .00


Processing Information
Please indicate all methods of processing you plan to utilize. If you already utilize an Internet payment gateway, we will work with that gateway to change the associated merchant account. If you already own or lease equipment or software, a simple reprogramming is all that's needed to bring you on-line with PayNet. If you need to establish a relationship with an Internet payment gateway, or would like to purchase equipment or software, please speak with a PayNet representative.
Internet solution/PC-based software (Please select)
	#	Make/Model
Terminal(s)
Printer(s)
Pin Pad(s)
If you currently accept any of the following card types, please provide your merchant numbers.
American Express
Discover (Novus)
If a card is present at the time of a sale, you should obtain either a magnetic stripe reading or a physical imprint to preserve your rights in the event of a chargeback. We can provide imprinters (at $30 each; please contact a PayNet representative) and imprinter plates (free of charge) if needed.
How many imprinter plates do you require?
As part of the application process, you must authorize us to investigate the creditworthiness of the business and its principals. You will do this in writing when you submit your application. You may also do it now. We recommend that you do it now, since it will allow us to pre-approve the application and smooth the application and setup process considerably.
I authorize PayNet Merchant Services Inc. to investigate the creditworthiness of this business and its principals. (Please check)