1. Please fill out all fields below marked with an *.
(Incomplete information will not be processed.)
2. Click the "View" button at the bottom of the page.
(This will popup a window with your next two steps in aquiring a Merchant Account
.)

Click on the icon if you need help for a particular field
or give us a call @ 361-241-3150.



Please select the services you wish to apply for:

Internet Merchant Account Merchant-Store Gateway Account
PayPal Link Gateway Account
Domain Hosting Account
PayPal Pro Gateway Account

 

Trade or DBA Name:
*
Legal Name:
*
Fed Tax ID or Social Security #:
*
Street Address:
* No P.O. Box
City/State/Zip:
*
Mailing Address:
City/State/Zip:
Telephone:
*
Alternate Phone:
Fax #:
Email:
*
Main Website Address:
*



Please be very accurate in the following section

Month and Year Business Formed:
*

Business Type:

*
Prior Business Names Used (if any) :
Premises Type:
*
Approx. Sq. Ft:
*
Landlord at Business Premises:
*
Landlord Phone:
*
Do you currently accept Visa-MC at this or any other business:
*
Processor Name:
Does a Physical Retail Store Exist:
*
Have You Ever Been Terminated For Services:
*
If Yes, Explain:
Estimated Monthly Visa-MC Volume:
*
Estimated Average Visa-MC Ticket:
*
Accept American Express cards:
*
If Existing, What Is Your Amex #:
Accept Discover cards:
*
If Existing, What Is Your Discover #:
If Existing, What Is Your Diners #:
(Diners Card require seperate application after Merchant account approval)
Additional business contact:
*
Additional Contact Title:
*
Additional Contact Phone:
*
Additional Contact Email:
Reason For Selecting Merchant-Store.com/FMBS:
*



Please be very accurate in the following section

Product Or Services Sold (be very specific):
*
Manufacturer(s):
*
Detail Manufacturer Warranty (if any):
Do You Offer Any Additional In-house Warranty:
*
If Yes, Detail:
Is a Return Merchandise Auth # Required:
*
Refund Policy (be very specific):
*


Note: Any Warranty and/or Refund Policy should be limited and must be conspicuously disclosed!
(It is acceptable to offer no warranty and/or "all sales final")

How are cardholders advised of Warranty or Refund Policies:
*
Is Customer Service Performed In-house
or by a 3rd Party?
*
Customer Service Phone #:
*
Customer Service Hours:
*
3rd Party Customer Service Provider Name:
3rd Party Customer Service Provider Phone:
Is Fulfillment Performed In-house
or by a 3rd Party?
*
3rd Party Fulfillment Provider Name:
3rd Party Fulfillment Provider Phone:
Describe Fulfillment Process:
*



Bank Reference *
Contact *
Phone *
Trade Reference *
Contact *
Phone *
Trade Reference *
Contact *
Phone *



Name : * Title: * % Ownership: *
SS#: * DOB: * Home Tel: *
Home Address: * No P.O. Box
City/State/Zip: *



Name : Title: % Ownership:
SS#: DOB: Home Tel:
Home Address: No P.O. Box
City/State/Zip:



ACCOUNT NAME: *
BANK NAME: *
ACCOUNT #; *
ADDRESS: *
FRD/ABA #: *
CITY/STATE/ZIP: *