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Merchant Services
Pricing
Industries
Business Needs
Solutions
Contact Us

Apply

Apply Now

Have a general question? Call our merchant services team and we’ll guide you in the right direction

702-655-5556

Application Form

First Name

Last Name

Email Address *

Phone Number *

Tell Us About Your Business

Business Name(DBA)

Corporate Street Address

City

State/Province

ZIP / Postal Code

Location Phone # *

Location Fax #

Customer Service Phone # *

Website Address

Corp/Legal Name(if different than DBA) *

Billing Address

Street Address

City

State/Province

ZIP / Postal Code

Country

Contact Name *

Contact Phone # *

Business Email Address *

Send Retrieval/Chargeback Requests to *

MC / Visa / Discover / American Express Optblue

Estimated MC/Visa/Discover Average Ticket/Sales Amount *

American Express OptBlue® Annual Sales Vol. *

Annual MC/Visa/Discover Volume: *

Estimated American Express OptBlue® Average Ticket *

Highest Ticket Amount: *

Provide More Business Data

Business Type

State Incorporated

Business Start Date Month/Year Started:

Length of Current Ownership

Seasonal Merchant?

Corporation Type of Ownership

Tax Type:

Tax Filing Name (as it appears on your income tax return) *

Federal Tax ID#: (as it appears on your income tax return) *

I certify that I am a foreign entity/nonresident alien. (If checked, please attach IRS Form W-8.)Yes

Card Present Mag Swipe/Card Dipped/Contactless % Number *

Card Present Not Swiped % Number *

Keyed Manually % Number *

Sum(Should Equal 100%)

%

Product/Services You Sold: *

Please make the above sum equal to 100%

Sales to Consumers % Number *

Sales to Business. % Number *

Sales to Govt. % Number *

Days to deliver order *

Prior Processor *

Bank Information

Bank Name *

Bank Contact Full Name *

Bank Contact Phone *

ABA # *

DDA # *

Provide Your Owner Information

Provide the following information for each individual who owns, directly or indirectly, 25% or more of the equity interest of your business.

How many owners have 25% or more ownership in your company? *

Owner/Partner/Officer Name #1

D.O.B

Social Security #

Home Phone

Mobile Phone

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Owner’s E-Mail Address *

Title

% of Ownership *

If you had a prior bankruptcy what type of bankruptcy was it? *BusinessPersonalNo Bankruptcy

If yes, date discharged

Owner/Partner/Officer Name #2

D.O.B

Social Security #

Home Phone

Mobile Phone

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Owner’s E-Mail Address *

% of Ownership *

If you had a prior bankruptcy what type of bankruptcy was it? *BusinessPersonalNo Bankruptcy

If yes, date discharged

Owner/Partner/Officer First Name #3

Owner/Partner/Officer Last Name #3

D.O.B

Social Security #

Home Phone

Mobile Phone

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

% of Ownership *

Owner’s E-Mail Address *

If you had a prior bankruptcy what type of bankruptcy was it? *BusinessPersonalNo Bankruptcy

If yes, date discharged

Owner/Partner/Officer Name #4

D.O.B

Social Security #

Home Phone

Mobile Phone

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

% of Ownership *

Owner’s E-Mail Address *

If you had a prior bankruptcy what type of bankruptcy was it? *BusinessPersonalNo Bankruptcy

If yes, date discharged

POS Order Form

Contact *

Telephone *

Products

Quantity of CloverStation Solo Bundles ($1350 with cash drawer)

Quantity of CloverStation Solo Bundle ($1224.99 without cash drawer)

Quantity of CloverStation DuoBundle ($1599 with cash drawer)

Quantity of CloverStation DuoBundle ($1475 without cash drawer)

Quantity of CloverMini ($699)

Quantity of CloverFlex ($549)

Quantity of Clover Go Bundle ($139)

Total Cost

Software

Basic payment acceptance functionality ($0.00/mo per device)

Accept payments and run your business ($14.95/mo per device)

Full featured POS for various verticals ($44.95/mo for first device + $9.95/mo for each additional device per location)

Vertical based POS for QSR merchants ($44.95/mo for first device + $9.95/mo for each additional device per location)

Vertical based POS for FSR merchants ($74.95/mo for first device + $9.95/mo for each additional device per location)

Please do not fill in this field.

Apply

Apply Now

Application Form

Tell Us About Your Business

Billing Address

MC / Visa / Discover / American Express Optblue

Provide More Business Data

Bank Information

Provide Your Owner Information

Provide the following information for each individual who owns, directly or indirectly, 25% or more of the equity interest of your business.

POS Order Form

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