Merchant Application - Association Merchant Services

Merchant Information Sheet

Please complete the following form accurately. All fields marked with * are required.

Page 1 of 5

Business Name (DBA Name)

Business Street Address

Business City

Business State

Business Zip Code

Business Phone

Business Email

Business Contact Person

Business Contact Title

Business Contact Cell Phone

Years in Business

Is Business & Corporate Address Same? * Yes No

Corporate Name (Tax ID Name) *

Federal Tax ID (NO DASHES) *

Corporate Street Address *

Corporate City *

Corporate State *

Corporate Zip Code *

Owner's Full Name *

Owner's Date of Birth *

Owner's SSN (no dashes) *

Owner's Home Address *

Owner's Email *

Point of Sale Type *

Number of Registers *

PIN Pad Type *if known

Business Closing Time *

Statement Type * Mail Email

Bank Name *

Bank Routing Number *

Bank Account Number *

Check/Bank Letter Upload (Optional) Accepted formats: PDF, DOC, DOCX, JPG, JPEG, PNG, GIF, WEBP, BMP, SVG, ICO, TIFF (Max 5MB)

FNS Number

Any additional information for AMS