- Advisor's Section -

Credit Card Processing Application Form

    Origination Questions

    Have you met the merchant face to face?

    Where did you meet the merchant?

    Did you solicit the merchant or did the merchant reach out to you?

    How did you receive the merchant lead?

    Office Use Only (to be filled out by Advisor)

    Company Name

    Business Phone Number

    Total Annual Revenue

    VISA Vol.

    MC Vol.

    Interac Vol.

    Discover Vol.

    Amex Vol.

    UPI Vol.

    Funding Run

    Bank Deposit Separator

    9:30pm EST11:30pm EST

    YesNo

    What type of Transactions (%)?:

    eCommerce

    Moto

    In Person

    Delivery Time Frame (Days) (%)?:

    0-7

    8-14

    15-30

    31+

    eCommerce Platform

    Shopping Cart

    Payment Gateway

    Auto Batch Time (EST)Required for Clover devices.

    SoftwareRequired for Clover devices.

     

    Advisor

    Advisor Notes:

    Pricing:

    Rate

    CC Transaction

    Debit Transaction

    Monthly Fee

    Equipment:

    If purchasing on Installment Plan, include number of months/payments term in the Notes section.

    Device:

    Price:

    Quantity:

    Rent/Purchase:

    Clover Flex V3

    Clover Mini V3

    Clover Station DUO

    Clover Station Solo

    Accessories:

    Accessory:

    Price:

    Quantity:

    Cable Kit

    $100

    Travel Kit

    $40

    Clover Mini Swivel Stand

    $50

    Handheld Barcode Scanner

    $189

    Handsfree Barcode Scanner

    $275

    Kitchen Receipt Printer

    $439

    Star Thermal Order Printer

    $379

    Epson Label Printer

    $699

    Mini-to-Mini Tether Cable

    $20

    Cash Drawer

    $169

    Integrated Weight Scale

    $449

    Elavon Applications Only - Fiserv Applications skip to Submit

    Business license or Incorporation Certificate:
    Company Tax ID:
    How will the agreement be signed?:

    PCI Fee Type:
    PCI Fee Amount: $