Please fill out this form as completely as possible. However, if there is any information that you do not have available or any question you do not understand, simply leave that section blank, and our staff will help you to obtain the missing information when we process your application.

It is essential, however, that you make sure to fill out your contact information, such as your name, email address, mailing address, phone number, and fax number (if you have a fax machine).

Remember that all of this information will be kept completely confidential. Charge.Com will not share any of your contact information with anyone under any circumstances.

Please make sure that all names and addresses are spelled correctly. This is exactly how they will appear on your merchant account file.

Owner's Name:   Mr.   Ms.   Dr.
First:     Middle Initial:     
Last:

Type of Ownership:
Sole Proprietor
Partnership
Corporation

Date of Birth (MM/DD/YY): / /

Contact Name, If Different:

Legal Name of Business:

Doing Business as (DBA), If Applicable:

Location of Business (No P.O. Boxes. If Home-Based, Enter Home Address):

Suite or Apartment # If Applicable

City: State:
 ZIP:

Country:
If Outside the USA, Please Enter Country Here:

If home address is the same as business address, click this box:

Home Address:

Suite or Apartment # If Applicable

City: State:  
ZIP:

Country:

Home Phone Number: ( ) -

Business Phone Number: ( ) -

Best Phone Number To Reach Applicant: ( ) -

Fax Number: ( ) -

Your Email Address:

Your World Wide Web Address (If Applicable):

Please enter approximate credit card sales. If you are not sure, please enter your best estimates.
Total sales should equal 100%.
Percent Combined Phone and Mail Orders: %

Percent Internet Orders: %

Percent Retail (Credit Card is Present and Swiped) Sales: %
 

Product or Service Sold:

Estimated Amount of Average Credit Card Sale: $

Estimated Monthly Credit Card Volume: $

Do You Currently Accept Visa, MasterCard, or American Express?
Yes
No

Which Credit Card Processing System Do You Want to Use?
Real-Time Processing with Virtual Terminal (Processing for Companies with a Web Site)
PC Software (Manual Processing for Companies with no Web Site)
Macintosh Software (Manual Processing for Companies with no Web Site)
Terminal without Printer with Manual Imprinter (Face-to-face Sales)
Terminal with Printer ($5.00 per month extra for lease, or $100 extra for purchase)

Do You Want to Buy or Lease the Processing System?
Buy
Lease

Please Feel Free to Send Us Any Comments You May Have.

** By Federal Law, All Information Provided Will Remain Confidential **

To become a credit card merchant, click the submit button:

Press only once and please wait for the confirmation page.
This may take up to 30 seconds.