eProfit - merchant transaction processing

1-800-295-4654

sales@eProfitinc.com

Becoming an eProfit Merchant is easy...

	Please contact us for an application
	To speak to one of our Customer Service Representatives call 1-800-295-4654.

Or simply complete the form below:
Merchant Name: (Legal name of Business)

Doing Business As Name:

Contact Name:

Mailing Address:

City:

State:

Zip:

Phone:

Fax:

Date Business Started with Current Owner:

Business Format:
Corporation Partnership Sole Proprietorship LLC
Business Description:

Total Annual Sales: $
Federal Tax Id: (EIN #)
Estimated Visa/MasterCard Annual Volume: $
Average Sale Per Customer: $
Total percentage of credit card transactions which are mail order, telephone order or pre-authorized: %

Presidential/Owner/Partner Information:
Name:

Social Security #:

Date of Birth:

Home Address:

City:

State:

Zip:

Home Phone:

Bill application Fee to: (optional)
   MasterCard    Visa    American Express Discover
Credit Card #: (optional) Expiration Date:
Do you currently accept MasterCard/Visa? Yes No
  If yes, do you currently have an electronic terminal? Yes No
  If yes, please provide terminal type and Serial #
Do you currently have an electronic Printer? Yes No
  If yes, please provide the printer type and Serial #
Do you currently accept American Express? Yes No
  If yes, please provide American Express SE#
Do you currently accept Discover? Yes No
  If yes, please provide Discover SE#
Your e-mail address: