Merchant Application | First Financial ®

Merchant Online Application

Merchant Application:

If you process or intend on processing through credit card terminals or a POS System complete the form below.

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:

Sales Representative:

Promo Code:

Enter Code Shown:*

Enter this code in the box to the right.

First Financial® Corporation - 7920 Miramar Road Suite 125 - San Diego, CA 92126
Toll Free Phone: 1-800-315-7791 Fax: 1-800-215-0217

First Financial® is a Federally Registered Trademark
Service Mark - Principle Register - For: Banking and Financing Services IN Class 36 U.S. Classes 100, 101, & 102 Reg. No. 3,532,314 Registered Nov 11^th, 2008 - SN. 77-415,637, Filed 3-6-2008 - USPTO - United States of America

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Merchant Online Application

Merchant Application: