Company officer/ Owner/ Principal Name:

Title

Email

Date of Birth:

Home Address:

City:

State:

ZIP Code:

Home Phone Number:

Driver's License Number:

Driver's License State:

Social Security Number:

Are there additional owners of the company?

Yes No

Date Established:

years in current location:

Description of Products or Services Sold:

URL(web site address) or eBay Seller ID:

Are your customers requires to pay a deposit when ordering?

Yes No

Do you currently accept credit cards?

Yes No

If yes, Name of Processor:

If not, have you ever accepted credit cards?

Yes No

If yes, Name of Processor:

Reason for Cancellation:

Monthly Visa/MC sales (estimate):

average transaction amount

maximum per transaction amount (required in order to "underwrite" your Merchant Account)

If you currently accept American Express, what is your 10 digit account number?

If you currently accept Discover, what is your 15 digit account number?

What is your typical time frame until product/ service is delivered?

What is your refund/ exchange/ cancellation policy?

All Sale Final Exchange Only Other

number of days that you will issue a full refund

Are there additional owners of the company?

In-House Manufacturer Only Don't have One

Number of days that the product or service is under full warranty?

I acknowledge and agree that by signing below and/or clicking the "Submit" button that I have read and understood, and agree to be bound by the terms and conditions of the Integrated Payment Services Merchant Application and the Internet Merchant Agreement and its appendices, including without limitation the Integrated Payment Services Pricing and all other fees.

Title

I acknowledge and agree that Authorize.Net and/or its Suppliers may obtain various consumer reports regarding Applicant from third parties, run a check on Applicant and/or obtain other personal or credit information about Applicant. I represent and warrant that I have the full power and authority to bind my company to the Agreement. Regardless of whether or not the Agreement is accepted or rejected, I acknowledge and agree that my personal information will be retained in a fraud detection database.

Owner's Signature:

Print name:

Date: