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Request Form
Now applying for Citycard’s top-notch services is just a point and click away. We’ve made it easy for you to join the Citycard family without having to set foot inside our offices! So don’t get up and apply now! We’ll let you know how you will qualify.
Part 1
Application Type:
Business Name (DBA):
Existing Merchant ID:
Business Address:
City, State & Zip Code:
Business Phone :
Business Fax :
E-mail Address:
Contact Name:
First:
Last:

Part 2  -  Corporation Information (complete only if different to Part 1)
Corp. Name:
Corp. Address:
City, State & Zip Code:
Corp. Phone :
Corp. Fax :
Contact Name:
First:
Last:

Part 3
Fax retrieval requests/mail chargebacks to:
Statement/Billing Address:
Time Zone:

Part 4  -  Ownership Information (Principal Owner or Officer/Partner/LLC Manager or Member)
Name:
First:
Last:
Date of Birth:(mm dd yyyy)
Social Security Number (SSN):
Title:
Phone:
Percentage Ownership:
Home Address:
City, State & Zip Code:

Part 5  -  Business Information
Year Established
Length of Current Ownership:
Years:
Months:
Do you have prior experience in similar business? If yes, how many years?
Years
Services or Products:
Business Structure:
Federal Tax ID or SSN:
(must be completed or application will be pended)
Current Bankcard Processor:
Have you or the business been a party to any claims or lawsuits:
Have you or the business declared bankruptcy:
Card Acceptance Method
(must equal 100 %)
Card Present (swipe) %
Card Present (no swipe) %
Mail Order %
Telephone Order %
Internet %
Average Credit Card Ticket ($ amount):
Monthly Credit Card Volume ($ amount):