MerchantChecks.com - All encompassing solution for online e-commerce

MerchantChecks - Your Total E-Commerce Solution

SIGN UP REQUEST FOR
MerchantChecks^SM SERVICE

PLEASE COMPLETE ALL FIELDS
IN THE FOLLOWING FORM
IF NOT APPLICABLE ENTER "N/A"

Merchant's Name on Checking Account:
Merchant Address:
Merchant City:
Merchant State:
Merchant Zip:
Merchant Phone Number:
Merchant Email Address:
Merchant Fax Number:
Merchant Bank Name:
Merchant Bank Address:
Merchant Bank City, State & Zip:
Merchant Bank Phone Number:
Merchant Bank Account Number:
Merchant Bank Routing Number:

Date of Application: ( MM/DD/YYYY )

APPLICATION PREPARED BY:

Title of Person Preparing this form:

Security password to be used to verify user. (example mothers maiden name- name only you would know) Will be required for technical support and changes to the system with technical staff.
Social Security Number or Federal Tax Payer Identification Number
State Tax Payer Identification Number
State Resale Certificate (If applicable)
TYPE OF ENTITY: Corporation Partnership Sole Proprietor Other:	If Other, please specify:
CLICK BELOW AND READ THE LICENSE AGREEMENT:
Do you agree with the terms and conditions of the license agreement: YES / NO

PLEASE PRINT OUT A COPY OF THIS PAGE: Within the next 24 hours, you will receive your temporary password, instructions to set up your company information, shopping cart information and access to the MerchantChecks^SM secured server via e-mail.

FOR ANY FURTHER INFORMATION, PLEASE SEND E-MAIL TO: techsetup@merchantchecks.com

M/C Systems
7119 E Shea Blvd., Suite 109-443
Scottsdale, AZ 96254
Phone: 480-922-0498
Fax: 480-922-9525
E-mail: info@merchantchecks.com

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