AuthorizeNet - Merchant Fees
Order Your Merchant Account


Complete this form and one of our sales
representatives will contact you shortly.
All information is kept confidential and is only used to process your order.

Business Information:
Email
Address: 		Business Name
Business Address Suite
City State
Zip D.B.A.
Type of Products or Services Business Hours Open
Closed
% Mail Order Numbers Only! % Phone Orders Numbers Only!
% Trade Show Numbers Only! Federal Tax ID #
Principal Contact Title
Phone Number
Numbers Only		 Fax Number
Numbers Only
Type of Business Sole Proprietorship
Partnership
Corporation		 Years in Business Numbers Only
Date Acquired
Owner/Principal Information:
President/
Owner		 Title
% Ownership Numbers Only S.S.# (Required) Numbers Only
Home Address City
State Zip
Housing I Own Rent Since
Home Phone #
Numbers Only		 Prev. Address
(if less than 3 years)
  Date of Birth
Drivers License# Expiration Date:
MM/DD/YY
State:
Co-Owner Information (If Applicable):
Co-Owner Name Title
% Ownership Numbers Only S.S.# (Required) Numbers Only!
Home Address City
State Zip
Housing I Own Rent Since
Home Phone #
Numbers Only		 Prev. Address (if less than 3 years)
  Date of Birth
Nearest Living Relative or Friend Not Residing With You:
Name: Relation
Address: City
State Zip
Home Phone #
Numbers Only
Equipment Information:
Type of Processing Equipment
(required to process credit card transactions)		 PC Software Terminal
Terms: Lease Purchase Reprogram Existing Equipment
Business References (List Media, Printers, Suppliers, Etc.)
Bank
Phone
Numbers Only		 Contact
Business or Trade
Phone
Numbers Only		 Contact
Business or Trade
Phone
Numbers Only		 Contact
Link Your URL:
Would you like to have a hyperlink to your site added to our links section ? This will allow our customers and associates to also view your web site and potentially purchase your products or services. Yes No
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APT POINT NET, Inc. #1 ISP in Miami

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