APPLICATION

If you need help or have questions contact us by phone 1-800 MRC-1292 or our online chat support .

 IS YOUR BUSSINESS SEASONAL?    
  TYPE OF LEGAL ENTITY:
  IF OTHER (provide details):      
FEDERAL TAX ID NUMBER OF LOCATIONS TO BE SET-UP
 TYPE OF BUSINESS:
BUSINESS LEGAL NAME (IF ORGANIZED AS A SOLE PROPRIETORSHIP , MUST BE OWNER’S PERSONAL NAME)
 
CORPORATE PHYSICAL ADDRESS (PHYSICAL ADDRESS ONLY—NO PO BOXES)
CITY STATE ZIP
YEARS AT ADDRESS
CORPORATE MAILING ADDRESS (IF DIFFERENT FROM PHYSICAL ADDRESS )
CITY STATE ZIP
BUSINESS PHONE include area code BUSINESS FAX
YEAR OF CURRENT OWNERSHIP ESTABLISHMENT YEAR OF BUSINESS ESTABLISHMENT
HAVE YOU SUFFERED A SYSTEM INTRUSION OR “HACK” THAT RESULTED IN THE COMPROMISE OF ACCOUNT DATA ?
HAS THIS BUSINESS EVER FILED BANKRUPTCY?
EMAIL  
Terminals /POS System needing to be converted

TERMINALS
NUMBER
POS SYSTEM
NUMBER OTHER POS NOT LISTED
NUMBER Please use this section to explain any information that we may need that is not listed i.e., printers, Pin Pads etc...
NUMBER
NUMBER
NUMBER
NUMBER
DO YOU ACCEPT AMERICAN EXPRESS?
IF YES, MERCHANT ACCOUNT #

NAME    TITLE    %OWNERSHIP   
DATE OF BIRTH  
HOME ADDRESS (PHYSICAL ADDRESS ONLY-NO PO BOXES)   
YEARS AT ADDRESS    HOME PHONE    CELL PHONE  
  CITY     STATE    ZIP   

* Please PRINT THIS PAGE and FAX it to us.
* Please also FAX at least two months statements.

Fax Us    
1-800-MRC-0392 (1-800-672-0392)

» IF SETTING UP MORE THAN ONE LOCATION, PLEAS PROVIDE LOCATION NAME ADDRESS, CONTACT NAME, PHONE, FAX AND E-MAIL FOR EACH LOCATION
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©2009 MRC Merchant Relief Council  I  1401 Yorba Street, Suite 100  I  Tustin, CA 92780  I  Phone: 1-800 MRC-1292  I  Fax: 1-800-MRC-0392
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