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Merchant Account Request Form:

  

Complete the form below or call 1-800-208 FDIS to open an account today.

 

98% of merchant accounts get approved. We specialize in high risk accounts and are not driven by a credit score. We can help you start processing cards at your business even if your business has no credit.

Merchant Division: *
Business Legal Name: *
Business DBA Name: *
Feredal ID #: *
Date Business Started: *
Type of Business: *
Business/Products/Services Sold (Be specific): *
Business Physical Street Address: *
City: *
State: *
Zip Code: *
Same as above: * Yes
No
Mailing Street Address (If different):
City:
State:
Zip Code:
Business Phone #: *
Business Fax #: *
Preferred Contact Phone #: *
Owner / Officer Name: *
Title: *
Ownership %: *
Date of birth: *
Social Security #: *
Drivers License No.: *
State Issued: *
Expiration Date: *
Email: *
Home Phone #: *
Cell Phone #: *
Street Address: *
City: *
State: *
Zip Code: *
Bank Name: *
Bank Contact: *
Phone #: *
Fax #: *
Transit Routing No.: *
Account No.: *
Merchant Customer Service Telephone: *
Merchant Customer Service E-Mail: *
Merchant Email: *
Merchant URL: *
Other Authorized Contact Person:
Comments:
Second Owner: * Yes
No
Second Owner Name (If applicable):
Ownership %:
Title:
Home Telephone #:
Date of Birth:
SS#:
Street Address:
City:
State:
Zip Code:
Promo Code:
Expected Monthly Volume: *
Average Ticket Amount: *
Highest Ticket: *
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