Accept credit cards thru e-commerce & retail merchant accounts - Free Gift, Apply Now -- ECScards -- Application for Merchant Services

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Merchant Processing Application
Please fill in the following information as completely as possible. Required fields are marked with a *. When you are finished, click on the 'Send' button at the bottom of the page.


* Business Legal Name: * Mailing Address: * City/State/Zip: * Phone Number: (xxx-xxx-xxxx) * SSN or Federal Tax ID Number: Internet Site/Web Site Address:	* Business Name or DBA Name: Street Address (If Different From Mailing): City/State/Zip: Fax Number: (xxx-xxx-xxxx) * Merchandise/Service Sold:

* Type Of Ownership:

Sole Proprietorship Partnership Corporation

LLC LLP Association/Trade

Non Profit Government International

* Date Business Started:
* Length Of Ownership: mo.
Previous Owner(If Applicable):
Previous Business Name(If Applicable):

* % Card Swiped

* % Hand Entered With Card Imprint

* % Hand Entered Without Imprint

Total Must Equal 100%

* % Retail * % Mail Ordered

* % Flea Market * % Trade Show

* % Phone Ordered * % Other

Total Must Equal 100%

* Monthly Bank Card
Volume:
Average Ticket:
* If volume equals or exceeds $50,000, additional documentation may be required.

* Name:

* Title: * Ownership %:
* Home Address:

* City/State/Zip

* Phone: (xxx-xxx-xxxx)
* Social Security:
* Date Of Birth: (MM/DD/YY)
Name:

Title: Ownership %:
Home Address:

City/State/Zip:

Phone: (xxx-xxx-xxxx)
Social Security:
Date Of Birth: (MM/DD/YY)

I/We authorize Bank or its authorized agent to obtain credit information as it may require concerning the statements made by me/us in the Application and agree that the Application shall remain Bank's property whether the request is granted or not.
I/We certify that all statements in this application are true and complete.

* Name:
* Date:" name="op1ab" size="10"> * Name:
* Date:" name="op2ab" size="10">

Important! Owners or Officers MUST type their full name and the date in lieu of a signature agreeing to the above terms.

Bank Reference Trade Reference 1 Trade Reference 2

* Name:

* Address:

City, Zip:

* Contact:

* Phone #:(xxx-xxx-xxxx)
* Name:

* Address:

City, Zip:

* Contact:

* Phone #:(xxx-xxx-xxxx)
* Name:

* Address:

City, Zip:

* Contact:

* Phone #:(xxx-xxx-xxxx)

\n"; $headers .= "Content-Type: text/html; charset=iso-8859-1\n"; mail ("$adminaddress", "Merchant Processing Application from $bna", "

Apply Online...

Merchant Processing Application
The following is what was submitted by an owner or officer of $bnb ($bna) on $date.

$\"bname.gif$

Business Legal Name:
$bna
Mailing Address:
$bnc
City/State/Zip:
$bnd
Phone Number: $bng
SSN or Federal Tax ID Number: $bni
Internet Site/Web Site Address:
$bnk
Business Name or DBA Name:
$bnb
Street Address
(If Different From Mailing):
$bne
City/State/Zip:
$bnf
Fax Number: $bnh
Merchandise/Service Sold:
$bnj

$\"mprofile.gif$

Type Of Ownership: $mpa
Date Business Started: $mpb
Length Of Ownership: $mpc mo.
Previous Owner(If Applicable): $mpd
Previous Business Name(If Applicable): $mpe

$\"vmcinfo.gif$

$vmca% Card Swiped

$vmcb% Hand Entered With Card Imprint

$vmcc% Hand Entered Without Imprint

Total Must Equal 100%

$vmsa% Retail $vmsd% Mail Ordered

$vmsb% Flea Market $vmse% Trade Show

$vmsc% Phone Ordered $vmsf% Other

Total Must Equal 100%

Monthly Bank Card
Volume: $vmbca
Average Ticket: $vmbcb
* If volume equals or exceeds $50,000, additional documentation may be required.

$\"ooprincipals.gif$

Name:
$op1a
Title: $op1b Ownership %: $op1c
Home Address:
$op1d
City/State/Zip
$op1e
Phone: $op1f
Social Security: $op1g
Date Of Birth: $op1h
Name:
$op2a
Title: $op2b Ownership %: $op2c
Home Address:
$op2d
City/State/Zip:
$op2e
Phone: $op2f
Social Security: $op2g
Date Of Birth: $op2h

I/We authorize Bank or its authorized agent to obtain credit information as it may require concerning the statements made by me/us in the Application and agree that the Application shall remain Bank's property whether the request is granted or not.
I/We certify that all statements in this application are true and complete.

Name:$op1aa
Date:$op1ab Name:$op2aa
Date:$op2ab

Important! Owners or Officers MUST type their full name and the date in lieu of a signature agreeing to the above terms.

$\"references.gif$

Bank Reference Trade Reference 1 Trade Reference 2

Name:
$rebra
Address:
$rebrb
City, Zip:
$rebrc
Contact:
$rebrd
Phone #:
$rebre Name:
$ret1a
Address:
$ret1b
City, Zip:
$ret1c
Contact:
$ret1d
Phone #:
$ret1e Name:
$ret2a
Address:
$ret2b
City, Zip:
$ret2c
Contact:
$ret2d
Phone #:
$ret2e

", "$headers"); PRINT "\n"; PRINT " \n"; PRINT " \n"; PRINT " Application for Merchant Services\n"; PRINT "\n"; PRINT "\n"; PRINT "
\n"; PRINT " Apply Online...
\n"; PRINT " \n"; PRINT "
Merchant Processing Application
\n"; PRINT " The following is what you submitted to ECScards on $date. Please print a copy of this page for your records. One of our Transaction Specialists will be getting in contact with you shortly to verify this information and complete the application process. Thank you.
\n"; PRINT " \n"; PRINT "
\n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT "
$\"bname.gif$
\n"; PRINT "
\n"; PRINT " Business Legal Name:
\n"; PRINT " $bna
\n"; PRINT " Mailing Address:
\n"; PRINT " $bnc
\n"; PRINT " City/State/Zip:
\n"; PRINT " $bnd
\n"; PRINT " Phone Number: $bng
\n"; PRINT " SSN or Federal Tax ID Number: $bni
\n"; PRINT " Internet Site/Web Site Address:
\n"; PRINT " $bnk\n"; PRINT "
\n"; PRINT " Business Name or DBA Name:
\n"; PRINT " $bnb
\n"; PRINT " Street Address
\n"; PRINT " (If Different From Mailing):
\n"; PRINT " $bne
\n"; PRINT " City/State/Zip:
\n"; PRINT " $bnf
\n"; PRINT " Fax Number: $bnh
\n"; PRINT " Merchandise/Service Sold:
\n"; PRINT " $bnj
\n"; PRINT "
\n"; PRINT "
\n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT "
$\"mprofile.gif$
\n"; PRINT " Type Of Ownership: $mpa
\n"; PRINT " Date Business Started: $mpb
\n"; PRINT " Length Of Ownership: $mpc mo.
\n"; PRINT " Previous Owner(If Applicable): $mpd
\n"; PRINT " Previous Business Name(If Applicable): $mpe\n"; PRINT "
\n"; PRINT "
\n"; PRINT "
\n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT "
$\"vmcinfo.gif$
\n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT "
$vmca% Card Swiped
$vmcb% Hand Entered With Card Imprint
$vmcc% Hand Entered Without Imprint
\n"; PRINT " \n"; PRINT " Total Must Equal 100%\n"; PRINT "
\n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT "
$vmsa% Retail $vmsd% Mail Ordered
$vmsb% Flea Market $vmse% Trade Show
$vmsc% Phone Ordered $vmsf% Other
\n"; PRINT " \n"; PRINT " Total Must Equal 100%\n"; PRINT "
\n"; PRINT "
Monthly Bank Card
\n"; PRINT " Volume: $vmbca
\n"; PRINT " Average Ticket: $vmbcb
\n"; PRINT " * If volume equals or exceeds $50,000, additional documentation may be required.
\n"; PRINT "
\n"; PRINT "
\n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT "
$\"ooprincipals.gif$
Name:
\n"; PRINT " $op1a
\n"; PRINT " Title: $op1b Ownership %: $op1c
\n"; PRINT " Home Address:
\n"; PRINT " $op1d
\n"; PRINT " City/State/Zip
\n"; PRINT " $op1e
\n"; PRINT " Phone: $op1f
\n"; PRINT " Social Security: $op1g
\n"; PRINT " Date Of Birth: $op1h
\n"; PRINT " Name:
\n"; PRINT " $op2a
\n"; PRINT " Title: $op2b Ownership %: $op2c
\n"; PRINT " Home Address:
\n"; PRINT " $op2d
\n"; PRINT " City/State/Zip:
\n"; PRINT " $op2e
\n"; PRINT " Phone: $op2f
\n"; PRINT " Social Security: $op2g
\n"; PRINT " Date Of Birth: $op2h
\n"; PRINT "
I/We authorize Bank or its authorized agent to obtain credit information as it may require concerning the statements made by me/us in the Application and agree that the Application shall remain Bank's property whether the request is granted or not.
\n"; PRINT " I/We certify that all statements in this application are true and complete.
Name:$op1aa
Date:$op1ab\n"; PRINT " Name:$op2aa
Date:$op2ab\n"; PRINT "
Important! Owners or Officers MUST type their full name and the date in lieu of a signature agreeing to the above terms.\n"; PRINT "
\n"; PRINT "
\n"; PRINT "
\n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT " \n"; PRINT "
$\"references.gif$
Bank Reference Trade Reference 1 Trade Reference 2
Name:
\n"; PRINT " $rebra
\n"; PRINT " Address:
\n"; PRINT " $rebrb
\n"; PRINT " City, Zip:
\n"; PRINT " $rebrc
\n"; PRINT " Contact:
\n"; PRINT " $rebrd
\n"; PRINT " Phone #:
\n"; PRINT " $rebre Name:
\n"; PRINT " $ret1a
\n"; PRINT " Address:
\n"; PRINT " $ret1b
\n"; PRINT " City, Zip:
\n"; PRINT " $ret1c
\n"; PRINT " Contact:
\n"; PRINT " $ret1d
\n"; PRINT " Phone #:
\n"; PRINT " $ret1e Name:
\n"; PRINT " $ret2a
\n"; PRINT " Address:
\n"; PRINT " $ret2b
\n"; PRINT " City, Zip:
\n"; PRINT " $ret2c
\n"; PRINT " Contact:
\n"; PRINT " $ret2d
\n"; PRINT " Phone #:
\n"; PRINT " $ret2e
\n"; PRINT "
\n"; PRINT "
\n"; PRINT " \n"; PRINT "
\n"; PRINT " \n"; PRINT " Page contents ©2000 ECScards. All rights reserved.
\n"; PRINT " \n"; ENDIF; ?>


* Name: * Title: * Ownership %: * Home Address: * City/State/Zip * Phone: (xxx-xxx-xxxx) * Social Security: * Date Of Birth: (MM/DD/YY)	Name: Title: Ownership %: Home Address: City/State/Zip: Phone: (xxx-xxx-xxxx) Social Security: Date Of Birth: (MM/DD/YY)
I/We authorize Bank or its authorized agent to obtain credit information as it may require concerning the statements made by me/us in the Application and agree that the Application shall remain Bank's property whether the request is granted or not. I/We certify that all statements in this application are true and complete.
* Name: * Date:" name="op1ab" size="10">	* Name: * Date:" name="op2ab" size="10">
*Important! Owners or Officers MUST* type their full name and the date in lieu of a signature agreeing to the above terms.**


Bank Reference	Trade Reference 1	Trade Reference 2
* Name: * Address: City, Zip: * Contact: * Phone #:(xxx-xxx-xxxx)	* Name: * Address: City, Zip: * Contact: * Phone #:(xxx-xxx-xxxx)	* Name: * Address: City, Zip: * Contact: * Phone #:(xxx-xxx-xxxx)

$\"bname.gif$
Business Legal Name: $bna Mailing Address: $bnc City/State/Zip: $bnd Phone Number: $bng SSN or Federal Tax ID Number: $bni Internet Site/Web Site Address: $bnk	Business Name or DBA Name: $bnb Street Address (If Different From Mailing): $bne City/State/Zip: $bnf Fax Number: $bnh Merchandise/Service Sold: $bnj

$\"ooprincipals.gif$
Name: $op1a Title: $op1b Ownership %: $op1c Home Address: $op1d City/State/Zip $op1e Phone: $op1f Social Security: $op1g Date Of Birth: $op1h	Name: $op2a Title: $op2b Ownership %: $op2c Home Address: $op2d City/State/Zip: $op2e Phone: $op2f Social Security: $op2g Date Of Birth: $op2h
I/We authorize Bank or its authorized agent to obtain credit information as it may require concerning the statements made by me/us in the Application and agree that the Application shall remain Bank's property whether the request is granted or not. I/We certify that all statements in this application are true and complete.
Name:$op1aa Date:$op1ab	Name:$op2aa Date:$op2ab
*Important! Owners or Officers MUST* type their full name and the date in lieu of a signature agreeing to the above terms.**

$\"references.gif$
Bank Reference	Trade Reference 1	Trade Reference 2
Name: $rebra Address: $rebrb City, Zip: $rebrc Contact: $rebrd Phone #: $rebre	Name: $ret1a Address: $ret1b City, Zip: $ret1c Contact: $ret1d Phone #: $ret1e	Name: $ret2a Address: $ret2b City, Zip: $ret2c Contact: $ret2d Phone #: $ret2e

$\"bname.gif$
\n"; PRINT " \n"; PRINT " Business Legal Name: \n"; PRINT " $bna \n"; PRINT " Mailing Address: \n"; PRINT " $bnc \n"; PRINT " City/State/Zip: \n"; PRINT " $bnd \n"; PRINT " Phone Number: $bng \n"; PRINT " SSN or Federal Tax ID Number: $bni \n"; PRINT " Internet Site/Web Site Address: \n"; PRINT " $bnk\n"; PRINT " \n"; PRINT "	Business Name or DBA Name: \n"; PRINT " $bnb \n"; PRINT " Street Address \n"; PRINT " (If Different From Mailing): \n"; PRINT " $bne \n"; PRINT " City/State/Zip: \n"; PRINT " $bnf \n"; PRINT " Fax Number: $bnh \n"; PRINT " Merchandise/Service Sold: \n"; PRINT " $bnj

$\"ooprincipals.gif$
Name: \n"; PRINT " $op1a \n"; PRINT " Title: $op1b Ownership %: $op1c \n"; PRINT " Home Address: \n"; PRINT " $op1d \n"; PRINT " City/State/Zip \n"; PRINT " $op1e \n"; PRINT " Phone: $op1f \n"; PRINT " Social Security: $op1g \n"; PRINT " Date Of Birth: $op1h \n"; PRINT "	Name: \n"; PRINT " $op2a \n"; PRINT " Title: $op2b Ownership %: $op2c \n"; PRINT " Home Address: \n"; PRINT " $op2d \n"; PRINT " City/State/Zip: \n"; PRINT " $op2e \n"; PRINT " Phone: $op2f \n"; PRINT " Social Security: $op2g \n"; PRINT " Date Of Birth: $op2h \n"; PRINT "
I/We authorize Bank or its authorized agent to obtain credit information as it may require concerning the statements made by me/us in the Application and agree that the Application shall remain Bank's property whether the request is granted or not. \n"; PRINT " I/We certify that all statements in this application are true and complete.
Name:$op1aa Date:$op1ab\n"; PRINT "	Name:$op2aa Date:$op2ab\n"; PRINT "
*Important! Owners or Officers MUST* type their full name and the date in lieu of a signature agreeing to the above terms.**\n"; PRINT "