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:
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
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:
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Alaska
District of Columbia
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
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:
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