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| Customer Information |
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Business Legal Name
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Is Your Business Seasonal
Yes
No
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Mailing/Billing Address
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City
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State
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Zip Code (xxxxx)
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Phone (xxx-xxx-xxxx)
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DBA Fax (xxx-xxx-xxxx)
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TAX ID # (xxxxxxxxx)
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*Total # of Locations
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Customer "Doing Business As" Name |
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*Customer “Doing Business As” Name
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Business Start Date (MM/YYYY)
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How Long At This Location
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*Location Address
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*City
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*State
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*Zip Code (xxxxx)
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Phone (xxx-xxx-xxxx)
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Primary Customer Contact
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*Email Address
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Business Information |
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*Type of Ownership
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Type of Business
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Describe Merchandise Sold
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Check Method of Advertising
Yellow Page Ads
Catalog
Direct Mail - Letter/Brochure
TV/Radio
Telephone/Marketing
Newspaper/magazines
Referral
Internet/Email
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Mail/Fax chargeback retrievals to
Outlet
Corporate
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Deliver statements to
Outlet
Corporate
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Deliver by
Mail
E-Mail
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Recon Solutions
Outlet
Chain
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American Express #
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Discover Merchant #
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Equipment Type
Rent
Purchase
Lease
Reprogram
Software Coding Only
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Sales Deposit and Refund Policy |
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% ANNUAL CREDIT CARD SALES GENERATED BY (TOTAL = 100%)
Mail/Phone
Internet
Card Swipe
Hand-Keyed Items Face-to-Face
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PERCENTAGE OF CUSTOMER ORDERS DELIVERED IN (TOTAL = 100%)
0 Days 1-7 Days
8-14 Days 15-30 Days More Than 30 Days
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NUMBER OF DAYS TO PREPARE SHIPMENTS FOR DELIVERY TO CUSTOMER FROM DATE OF ORDER
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ARE CUSTOMERS REQUIRED TO PROVIDE A DEPOSIT?
Yes
No
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IF A DEPOSIT IS REQUIRED, WHAT PERCENT OF THE TOTAL SALE IS REQUIRED? %
% of total sales
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MC/VISA SALES ARE DEPOSITED (CHECK ONE)
At Date Of Order
At Date Of Delivery
Other
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DO YOU HAVE A REFUND POLICY FOR YOUR MASTERCARD/VISA SALES?
Yes
No
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CHECK THE APPLICABLE REFUND POLICY
Exchange
Store Credit
MC/Visa Credit
Other
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IF MC/VISA CREDIT WITHIN HOW MANY DAYS DO YOU DEPOSIT CREDIT TRANSACTIONS?
0 -3 Days
4-7 Days
8-14 Days
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WHAT % OF PRODUCT/SERVICE DOES CUSTOMER RECEIVE AT TIME OF PURCHASE:
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Owner/Officer
Information |
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1. First Name
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Last Name
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Title
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Percent of Ownership, %
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*Residence Address
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*City
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*State
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*Zip Code (xxxxx)
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Home Phone (xxx-xxx-xxxx)
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Date of Birth
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Secial Security #
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Driver's License #
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Driver's License State
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2. First Name
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Last Name
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Title
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Percent of Ownership, %
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*Residence Address
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*City
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*State
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*Zip Code (xxxxx)
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Home Phone (xxx-xxx-xxxx)
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Date of Birth
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Secial Security #
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Driver's License #
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Driver's License State
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Company President
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Company CFO
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Credit Information |
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Annual Visa/Mastercard Volume
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Average Credit card Ticket
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Total Sales
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Mail or Telephone Order Sales (Complete if your sales are generated by
mail, telephone or Internet orders, or if your product is not delivered at the point of sale.) |
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Name of fulfillment house (if any)
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If Fulfillment house, who owns inventory?
Customer
Fulfillment House
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Delivery time frame
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Fulfillment house - street address
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City
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State
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Zip Code (xxxxx)
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Bank References |
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Bank Name
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Transit / Routing # (ABA #)
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Account Number
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Address
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City
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State
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Zip Code (xxxxx)
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If the customer has previously accepted credit cards, the last 3 months statements are
required |
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Current processing bank name
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Reason for leaving current processor
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Contact Person
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City / State
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Zip code
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Phone
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Have principals ever file bankruptcy?
Yes
No
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Chapter Filed
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Date
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HAVE ANY OF THE PRINCIPALS EVER MANAGED OR OWNED ANOTHER BUSINESS THAT ACCEPTED CREDIT
CARDS?
Yes
No
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If yes, provide business name
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City
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State
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SECOND PRINCIPAL
Yes
No
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If yes, provide business name
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City
|
State
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