Merchant Account Application

By submitting this form, each of the listed business and business owners/officers/members (individually and collectively, “you”) agrees to the review and approval process for a merchant services (credit card processing) account through the Jeison German Group and its affiliates including Fiserv, First Data, TSYS, Authorize.net with sponsor bank Wells Fargo. This may involve a credit check and verification of your business's credit card processing volume, the types of cards you accept, and additional information as needed to determine the best credit card processing rate available for you. A review of your most recent merchant statements may be required to complete this evaluation and to determine your new effective rate.

Business Information

Full Legal Name *

Physical Location Phone *

Email Address *

Preferred Contact Phone Number *

State of Incorporation *

DBA name. *

Cell Phone Number *

Fax Number (If applicable)

Business Address *

Address 2

City *

State *

ZIP *

Seasonal business? *

Yes

No

Type of business entity *

Business Start Date (MM/DD/YYYY) * +

Average Monthly Processing Amount (Dollars)

Which pricing program are you interested in? *

Please select one of the following to identify your business type: *

For Full-Service Restaurants, Quick Service Restaurants, or Retail stores our solution includes the mobile application, online ordering capability, and third-party integration with solutions like Door Dash, Uber Eats, and Yelp.

Please select your business consultant or referral partner if you already have one. *

Business EIN *

For merchant applications, a voided check and driver's license are required OR you may submit a bank letter. *

Owner/Officer 1 Information

First Name *

Last Name *

Email Address *

Ownership % *

Position/Title

Preferred Contact Phone Number *

Present Address *

Address 2

City *

State *

ZIP *

Owner's Date of Birth * +

Owner Social Security Number (Required but you may call to provide this if you prefer.)

Owner/Officer 2 Information

First Name

Last Name

Email Address

Ownership %

Position/Title

Preferred Contact Phone Number

Present Address

Address 2

City

State

ZIP

*Please note that your social security number or federal tax ID number is required to complete this application. We will call you to verify all information and securely take that by phone.