Request To Add Merchant Location General InformationNew Location Business Name: Web Address: Contact: Phone: Fax: E-mail: New Location Address Street Address Address Line 2 Date Est.: Products / Services Sold: Tax ID: Ownership (circle one): Corporation LLC Gen. Partnership Ltd. Partnership Proprietor Non Profit Type of Business (total must = 100%):Retail %Keyed / Phone Order %Internet %Restaurant %Lodging %Other % Add RemoveLandlord Name: Contact: Phone: Parent Company Name: Merchant ID: Contact: Phone: Fax: Parent Company Address: Terms and ConditionsAvg. Ticket: Mo. Volume: Max Ticket: Discount Rate: Trans. Fee: Banking (attach Voided Check)Bank Name: Transit / Routing #: Account #: Contact: Phone: Fax: Bank Address: Travel & Entertainment Cards ActiveAmerican Express Number: Establish New Location Account Yes No Discover Number: Establish New Location Account Yes No Diners Club Number: Establish New Location Account Yes No Point of Sale EquipmentEquipment Type: Order / Reprogram: Ship Address (if applicable) Ship Method:
