Merchant Pre-Application

We’re excited to help you take the next step in partnering with FSA.

FSA Pre-Application Form

Select Your Agent:

Business Information

Business Corporate/Legal Name:

DBA Name:

Location Address (No PO Boxes):

City:

State:

Zip:

Mailing address is different from location address

Business Phone #:

Business Fax #:

Business URL:

Primary Contact Name:

Email:

Federal Tax ID:

Length of Time in Business:

Ownership:

Acceptance Information

Card Present %:

Keyed %:

MOTO %:

Internet %:

Products/Services Sold:

Avg. Ticket:

High Ticket:

Annual V/MC/DISC Volume:

Annual Amex Volume:

Controlling Position / Beneficial Owner

Principal Name:

Title:

% Ownership:

Date of Birth (MM/DD/YYYY):

Social Security #:

Home Address:

City:

State:

Zip:

Home #:

Cell #:

Personal Email:

Bank Account Information

Bank Name:

Bank Contact/Phone #:

Account Type:

Routing #:

Account #:

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