Syminet :: E-Commerce Solutions

Web Hosting Solutions

Compare Hosting Plans

Manage Your Account

Register Your Domain

Transfer Your Domain

E-Commerce Solutions

Web Applications

Web Design Services

E-Commerce

Syminet Merchant Account Application

Please complete the form below to submit your application.
We will email your merchant agreement and further instructions.

Legal and Doing Business As Information
Legal Address*
Legal Name*
Legal City*
Legal State*
Legal Zip*
Legal Phone*
Legal Fax*
Legal Email*
Time Zone
Website Address
Federal Tax ID*
DBA Name*
DBA Address*
DBA City*
DBA State*
DBA Zip Code*
DBA Contact*
DBA Phone*

Merchant Profile Information
Type Of Organization*
Time In Business*
Product Services Sold*
Merchant Type:* Internet Gateway - Select this if you wish to process sales via the Internet. Other
Monthly Volume*
Average Amount*
Highest Amount*

Primary Owners Information
Name*
Percent Ownership*
SSN:		- -
Phone*
Address*
City*
State*
Zip Code*
Date Of Birth*

Secondary Owners Information
Name
Percent Ownership
SSN
Phone
Address
City
State
Zip Code
Date Of Birth

Prior History
		Do you currently accept VISA/MASTERCARD via another merchant account?
		Has your business or any principal been terminated as a VISA/MC merchant?
		Has your business or any principal filed bankruptcy or been subject to involuntary bankruptcy?

Business Website
Website Address
Temp Web Site URL (if actual site not yet completed)

Business Location
Merchant Location:
Own or Rent?
If Rent, Landlord Name:

Business Trade References - Clients, Vendors, Providers or Suppliers
* Business Name
* Contact Name
* Contact Phone

* Business Name
* Contact Name2
* Contact Phone2

Comments (optional)
		All * Are Required Fields

©2005 Syminet. All rights reserved.