Merchant Pre-Application

Please follow the simple form process below by filling out all the required fields marked with a *. If you have any questions during this process, please feel free to contact us at: 866-BMJGRP1. One of our representatives will be more than happy to assist you.
Visa Credit Discount Rate3.95% Visa Debit Discount Rate2.95%
MC Credit Discount Rate3.95% MC Debit Discount Rate2.95%
Credit Per Transaction Fee$0.25 Debit per Transaction Fee$0.25
Application Fee$195 Chargeback Fee$35
Annual Fee$199 Voice Authorization Fee$1.5
Monthly Statement Fee$15 Minimum Monthly Fee$350
Per Batch Fee$0.25 Retrieval Fee$10.00
Return Fee$1.50 AVS Fee$0.10
Gateway Transaction Fee$0.25 Gateway Monthly Fee$29.95
Gateway License Fee$1 

General Information
Contact Name:*
Legal Name *
 Doing Business As:*
Legal/Billing Address:*
 DBA/Location Address:*
City:*

State:*

Zip: * 		City:*



Zip: *
Business Phone:*
 Business Fax:
Federal Tax ID: *
 Time in Business:
Years Months
E-mail:*
 Web Site:*
Facebook Page:
 Twitter Handle:

First Principal Information
Name:*
   Ownership %:*
Email: *
 Officer's Title:*
Social Security #:*
 Home Phone:*
Residence Address:*
 City:*
State:*
Zip:*
Drivers License #:*
 DOB:*

Second Principal Information
Name:
   Ownership %:
Email:
Officer Title:
Social Security #:
 Home Phone:
Residence Address:
 City:
State:
Zip:
Drivers License #:
 DOB:

Business Account and Bank Information
Bank Name:*
 Bank Contact:*
Address:*

City:*
 State:*

Zip:*
Routing and Transit Number:*
 Account Number (DDA): *

Business Information
Business Open Date *
 Type of Ownership:*
Number of days until the product/service is delivered:
Internet Business
 
Average Ticket:*
Highest Ticket:*
Card Present Swipe *%
Card Present Imprint *%
Card Not Present (Ecommerce)*%
Card Not Present (MOTO)*%		 Principal has processed credit cards

If YES, with whom?
Has Principal been terminated by a credit card processor?

If Yes, by whom?
(Please provide an explanation regarding your termination below.)
SIC Code:
Specify type of Product(s) or services(s) sold:*
Shopping Cart:
Payment Gateway:

Bank and Trade Reference
Bank Name:
Bank Address:
 Bank City:
Bank State:
 Bank Zip:*
Bank Account Number:
 Bank Phone:
Trade Reference:
Trade Contact:
Trade Address:
Trade City:
Trade State:
Trade Zip:
Trade Account Number:
 Trade Phone:

Existing Merchant Numbers
If you have the following merchant ID numbers, please insert them in the appropriate fields.
AMEX Number:
 Diners Number:

Thank you for completing the application.
Click the "submit" button below ONE TIME to forward your application for processing and a representative will contact you shortly.

Should you need more immediate assistance, you may contact us at: 866-BMJGRP1
 
A Division of Advanced Merchant Group
208 E. Pennsylvania Blvd.
FEASTERVILLE TRE , PA 19053
Phone: 877.997.9473 Fax: 215.701.4989