Home page Company Services Sign Up! Security Customer Support Contact Us Merchant Pre-Application Please fill out the following short application. We will contact you by the next business day and let you know if you qualify. This is a free service and there is no cost or obligation. Please Note: The information you supply will be used only for the purpose of qualifying you for a merchant account by Global Virtual Payments affiliated banks. This information you provide is held in strict confidence and is never sold, rented, or shared with any other business or third party. BUSINESS INFORMATION Business Name: Business Address: City, State, Zip Code: Business Phone: Business Fax: Web Site Address: Type of Business: Please Select Sole Proprietorship Partnership LLC Corporation Business Start Date (MM/YY): Please describe products or services sold in a few sentences: Is the business based in the U.S., and does the owner have a U.S. SS#? Yes No Do you currently process Credit Cards? Yes No Estimated monthly card sales volume: Estimated cost per item or services: Order sources? (must equal 100%) Retail (card is present) % Internet/Mail/Phone (card is not present) % Please rate the owner's credit: Please Select Excellent Good Fair Poor Previous Bankruptcy Non established CONTACT INFORMATION Contact Name: E-mail Address: Best numbers to reach you at: Best time to call: Please Select As soon as possible Morning Afternoon Anytime Time Zone: Please Select EST CST MST PST Other How did you find us? Please Select AOL Altavista Excite Google GoTo Hotbot Looksmart Lycos MSN Yahoo Word of Mouth Authorize.net's page Your banner somewhere A link on someone's page Radio Ad Magazine Ad Don't remember Other Have you called us and spoken with anyone? Please Select No - never called Yes - Sales Rep. PROCESSING OPTIONS Option interested in (check all that apply): Authorize.Net Internet Processing PC Charge Software Point of Sale Terminal Have my own processing equipment (please specify type):        Unsure Notes or Comments:

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