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Merchant Services Application Form
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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:
Legal Business Name:
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
Main Business Contact Name
*Phone Number
Fax Number
*Email
Website:
*Business Type
Sole Proprietor
Partnership
Corporation
LLC
Tax Exempt
*Date of Business Established
*Primary Owner/Officer Name:
*Primary Owners Social Security Number
*Date of Birth
*Primary Owners Mobile Phone Number
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
Average Ticket $:
Federal Tax ID #:
Product/Services Sold
--- Select ---
Food & Beverage
Liquor
Gas/Oil
Other Retail
Other Services
Annual Visa/MC/Discover Sales $
Total number of locations:
Years Business Owned
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?
Business Phone
Cell Phone
Email
Upoad Picture of Business Voided Check for Deposits
gif,jpg,jpeg,png,psd,tif,tiff,heic,pdf
Upload Picture of Owners Drivers Licenses or ID
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Upload Business Certificate with EIN # and Business Address
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**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.
Referral by:
Optional
Submit Application
About
Our President
Products
Simphony Oracle POS
Revel POS
Talech POS
Clover POS
RPower POS
SoftTouch POS
VitaPAY POS
Online Ordering
Services
Payment Options
Careers
Contact
