Printable version requires
Adobe Acrobat Reader

Business Information
Merchants DBA Name/Outlet Name:
Merchants Legal Name:
Physical Street Address (No P.O. Box):
City, State, Zip:
Contact Name at this address:
Legal Address:
City, State, Zip:
DBA Phone:
Fax:
Corp. Phone:
Merchant Profile
Type of Ownership:

Sole Proprietor Partnership

Professional Assoc

Corporation Tax Exempts Org.

LLC Other

Years in business under current ownership?
Federal Tax ID#:
Cardholder Data Storage Compliance
Is Cardholder Data Stored?
yes no
Owner/Officer Information
Name:
Title:
Date Of Birth:
Home Address:
City, State ,Zip:
Years There:
Own/Rent:
Own Rent
Equipment / Terminal Applications
Terminal Type:
 Printer Type:
 

 

  
 
Turn future
Credit Card Sales
into Cash Today!
Find out more >>
   
 
800.827.4880
 
 

info@intlbancard.com

909 N. Main St.
Royal Oak, MI 48067
fax | 877.649.0021

International Bancard Corporation is a registered ISO and MSP for Global Payments Inc. and HSBC Bank USA, N/A
 
© International Bancard Corporation