VALIS International
New Merchant Pre-Application


Sales Information

*How did you hear about us?
Visa & MasterCard are included with your merchant account. Please indicate which additional services you would like to add to your account:
American Express:
(a $25 processing fee will be charged)
Existing Amex Merchant ID:
Discover:
(a $25 processing fee will be charged)
Existing Discover Merchant ID:
PayByCheck:

Business Information
*Business Name (DBA):
*Business Federal Tax ID#:
*Business Legal Name:
*Business Address:
(You can NOT use a PO box or a MailBoxes address)
*City, State, Zip:
*Country:
*Time Zone:
*Contact Name:
*Business Telephone:
(You can NOT use a toll free number) ESA International Access number goes here
- -
*Business Fax:
ESA International Access number goes here
- -
*Customer Service Telephone:
ESA Toll Free number goes here
- -
*E-Mail Address:
*Web Address (URL):
*Business Structure:
*Industry:
*Product/Service Sold:

Ownership Information
*Principal Owner/Officer #1:
*% Ownership:
*Title:
*Home Address:
(You can NOT use a PO box or a MailBoxes address)
*City, State, Zip:
*Country:
*Home Telephone:
(You can NOT use a toll free number)
- -
*Social Security Number
Enter EIN if no SSN:
- - ###-##-####
*Date of Birth:
/ /
Principal Owner/Officer #2:
% Ownership:
Title
Home Address:
(You can NOT use a PO box or a MailBoxes address)
City, State & Zip:
Country:
Home Telephone:
(You can NOT use a toll free number)
- -
Social Security Number
Enter EIN if no SSN:
- - ###-##-####
Date of Birth:
/ /

Additional Information Required
*Date Established:
eg. 1998
*Current Ownership # Yrs.:
*Current Ownership # Mos.:
*If you have prior experience in a similar business, how many years?
*Average Credit Card Ticket:
.00
No commas, decimals or $ signs
*Monthly Credit Card Volume:
.00
No commas, decimals or $ signs
Do you want your account to be closed down and unable to process for any months due to seasonal business?
Yes No

Which Months?
Januray
February
March
April
May
June
July
August
September
October
November
December

Qualifying Information
*In the past ten years, have you had:

Bankruptcy?
Yes No
Unpaid Tax Lien?
Yes No
Chargeoff?
Yes No
Repossession?
Yes No
Collections?
Yes No
If you already accept credit cards, how many chargebacks have you had in the past 6 months?
*How much inventory in dollar amount do you have in stock at the current time?
.00
No commas, decimals or $ signs

Do you advertise or market your product/service?
Yes No

Do you have any warranties, subscriptions or memberships?

Yes No
How much did you spend last month on advertising?
.00
No commas, decimals or $ signs
After charging customer, how many days do they generally wait before receiving product or service?
Where did you advertise?
Newspaper Magazine
TV/Radio Mail Internet
   
Existing Business Checking Account Information
Required only if you are not applying for our checking account.
* Bank Name:
*Address:
*City, State & Zip:
*Telephone:
- -
*Business Checking Account Number:
*Transit/Routing Number:
Notes:

Please Submit marketing materials to preapp@valisinternational.com if your web site is not up and running. Pictures of your products with prices, refund policy and customer service phone number are necessary if the bank cannot access your website. If your website is up and running, it must include your DBA on the homepage, products, prices, refund policy, & customer service phone number.


 
Please, Only Hit The Submit Button One Time