(802) 660-3980
GENERAL INFORMATION:
Legal Business Name
D.B.A.
Business Address
Suite
City/State/Zip
Describe Business (Name Product/Service)
Business Location ... Type of Building
Commercial Residential Retail
% Retail Sales
% Phone Orders/Mail Order
% Internet Sales
% Trade Show
# of Locations
Year Started
Age of Business
Fed Tax ID
Contact
Phone No.
Fax No.
Est. Card $/Mo.
Avg. $/Sale
Type of Business
Sole Prop. Partnership Corp.
President/Owner
Title
% Ownership
S.S.# (Req.)
Residence Address
Date Of Birth
Home Phone
.
Co-Owner (If Applies)
% Owned
How Did You Find Northern Merchant Services?
Please Rank Your Credit
Prior Chapter 7, 11, 13?
Year
Excellent Fair Poor
Yes No
Type of Processing Equipment (required to process credit card transactions) (Please Selected below)
Software/Real-time None Secure Pay with Shopping Cart Secure Pay w/o Shopping Cart NMS E-commerce Package NMS E-commerce Package w/o cart Verisign Payflow Link Verisign Payflow Pro Authorizer PCAuthorize PC Charge
Terminal None Omni 3200 Tranz 330 Tranz 380 X 2 Tranz 420
Terms: Lease -- None Selected 24 Months 36 Months 48 Months Purchase Reprogram Existing
Do you currently process Credit Cards?
Would you like to process Discover?{Setup fee $50.00} Yes No
Would you like to process American Express? {Setup fee free} Yes No
Your Email Address:
Send mail to webmaster@northernmerchant.com with questions or comments about this web site. Copyright © 1999 Northern Merchant Services. Last modified:Monday, March 05, 2001
Credit Card
Processing and Merchant Account 