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Business Profile for Merchant Services,(Information for application purposes only and is not a guarantee of acceptance) Please Note: The personal information you supply will be used only for the purpose of qualifying you for a merchant account by VITAPAY. This information is held in the strictest confidence and is never sold, rented, or shared with any other business or third party.
Business/DBA Name:
DBA Address:
City:
State
--- Select ---
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip
*Phone Number
Fax Number
Contact Name at DBA:
Website:
Legal Business Name:
Legal Business Address
City:
State
--- Select ---
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip
*Phone Number
Fax Number
Contact Name at Legal Business
*Email
*Mailing/Billing Address:
Use DBA
Use Legal
Other
*Date of Business Established
*Primary Owner/Officer Name:
*Primary Owner's Social Security Number
*Date of Birth
Residential Address
City
State
--- Select ---
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
Years at this address:
Own or Rent:
Own
Rent
*Business Type
Sole Proprietor
Partnership
Corporation
LLC
Tax Exempt
Average Ticket $:
Federal Tax ID #:
Product/Services Sold
--- Select ---
Food & Beverage
Liquor
Gas/Oil
Other Retail
Other Services
Years Business Owned
Annual Visa/MC/Discover Sales $
Total number of locations:
Type of Inventory:
Hours of operations
Surrounding Area:
Commercial
Residential
Industrial
Is the Premises:
Leased
Owner
Anticipated Date to begin processing:
Application for the following card services:
Visa/MasterCard/Discover
American Express
PIN-Based Debit
EBT
What email or fax number would you like us to send your application to?
What is the best way to contact you?
DBA Phone
Cell Phone
Email
Point of Sale System:
Dealer Name/Phone:
Upoad Picture of Business Voided Check for Deposits
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Upload Picture of Owners Drivers Licenses or ID
doc docx mpg mpeg mp3 mp4 odt odp ods pdf ppt pptx txt xls xlsx
Upload Business Certificate with EIN # and Business Address
doc docx mpg mpeg mp3 mp4 odt odp ods pdf ppt pptx txt xls xlsx
**This is not the final step in the process. VITAPAY will take this info and send an application to you for your review. Your processing account can be set up a few days after you return your signed official application.
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Our Company
Products
RPower Pos
InfoTouch Pos
MicroSale Pos
SoftTouch POS
Services
Careers
Contact Us
Login
Merchant Login
Client Access
