NEW ACCOUNT ACTIVATION
Please verify that the information below that you provided is correct.
Required items are marked with (*)
Merchant Information
Note: Failure to provide accurate information may result in a withholding of merchant funding per IRS regulations.
(See Terms and Conditions for further information)
*Legal Name of Business (as it appears on your income tax return)  
Doing Business As (DBA) (if applicable)
Best Phone Number To Reach Applicant  
Company Contact Name
*Email Address    
*Business Phone Number    
Fax Number  
*Business Street Address  
Business Suite # (if applicable)
*Business City  
*Business State  
*Business Zip Code    
Owner Information
*Owner's First Name  
*Owner's Last Name
*Social Security Number (For I.D. verification purposes)    
*Home Phone Number    
*Ownership Percentage %    
*Home Address  
Home Apartment # (if applicable)
*Home City  
*Home State  
*Home Zip Code    
*Owner's Date Of Birth      
Business Information
Business Website Address (if applicable)
*Describe Products Sold (i.e. I sell flowers)  
*Type of Ownership  
*Years of Ownership (enter 0 if less than 1 year)    
*Year Business Opened    
*Federal Tax I.D. Number of company as it appears on your
income tax return (Sole proprietors use Social Security Number)    
*Do you use drop-shippers or order fulfillment companies to ship products  
  List The Name(s) of Drop Shippers  
*Delivery Methods?  
*Card Charging Policies?  
*Return and Refund Policies?  
*Total Monthly Credit Card Sales (estimated) $    
*Average Individual Credit Card Sale Amount (estimated) $    
*Highest Individual Credit Card Sale Amount (estimated) $    
*How are Products Sold  
*Please Indicate your recurring billing frequency  
*Please provide a breakdown of how credit card orders will be received.
 Please use best estimates  
Internet %    
Telephone %    
Mail-Order %    
Face-to-face where card is swiped through a terminal %    
Face-to-face where card is not swiped but is imprinted %    
  Total must equal 100%
check  

*Name of the bank where you would like your funds deposited  
*Name on Bank Account  
*Routing/Transit Number    
*Account Number  
US Checking accounts only. No savings accounts are accepted.
Does your company or you, manage or own another business which already has a merchant account with Harris Bank or Pipeline Data Processing?
If yes, list name, address and Merchant#
Are you now processing or have you ever processed Discover®, MasterCard and/or Visa?
If yes, name of processor(s)
Have you ever had a credit card relationship terminated?
If yes, provide explanation:
*Does your system store Credit Card Data?  
*Are you PCI Compliant  
You will be setup to accept all cards unless any of the boxes below are checked-off
(checking-off any of the boxes below will limit your card acceptance -- see section 1. Honoring Cards):
Accept MasterCard Credit Transactions Only
Accept Visa Credit Transactions Only
Accept MasterCard Signature Debit Transactions Only
Accept Visa Signature Debit Transactions Only
Accept Amex Transactions Only
Accept Discover Transactions Only
Discover / Visa / MasterCard Rates And Fees
Discover / Visa / MasterCard Discount TXN Fees
MC Qual Credit-Rate 1 0.25 % $ 0.00
MC Mid Qual Credit-Rate 2 Rate 1 + 1.00 % $ 0.00
MC Non Qual Credit-Rate 3 Rate 1 + 1.00 % $ 0.00
MC Qual Debit-Rate 4 0.00 % $ 0.00
MC World Card Credit-Rate 5 Rate 1 + 0.00 % $ 0.00
Includes Dues and Assessments Percent TXN Fee
Pass Through Interchange Credit 0.25 % $ 0.00
Pass Through Interchange Debit Networks 0.00 % $ 0.00
Authorization and Transaction Fees
ACH Fee $ 0.25 Discover/Visa/MasterCard Authorization Fee $ 0.25 /each
Voice Authorization Fee $ 0.75 /each American Express Authorization/EDC Fee $ 0.25 /each
Debit/ATM Transaction Fee
(Plus Debit Network Processing Fees) 		$ 0.25 /each JCB Authorization/EDC Fee $ 0.25 /each
Discover Authorization/EDC Fee $ 0.25 /each ACH reject Fee $ 25.00 /each
Other Fees
Minimum Monthly Discount Fee $ 15.00 /month Annual Fee $ 99.00 /year
Chargeback Fee/Retrieval Fee $ 25.00 /each Monthly Fee/Gateway Fee $ 6.00 /month
Statement Fee $ 9.00 /month Merchant Club Fee $ 0.00 /month
Early Termination Fee $ 0.00    
* I hereby accept fees and account rates above and authorize Pipeline Data Inc to initiate credits and debits to my settlement account (see Section 6). I have read the Terms and Conditions.
All merchants are enabled for Visa and MasterCard acceptance
* I acknowledge receipt of the disclosure page.
* By signing below, I represent that I have read and am authorized to sign and submit this application for the above entity which agrees to be bound by the American Express ® Card Acceptance Agrreement("Agreement"), and that all information provided herein is true, complete and accurate. I authorize Cynergy Data, LLC and American Express Travel Related Services Company, Inc("American Express") and American Express's agents and affiliates to verify the information in this application and receive and exchange information about me personally, including by requesting reports from consumer reporting agencies, and disclose such information to their agents, subcontractors, Affiliates, and other parties for any purpose permitted by law. I authorize and direct Cynergy Data, LLC and American Express and American Express's agents and Affiliates to inform me directly, or through the entity above of reports about me that they have requested from consumer reporting agencies. Such information will include the name and address of the agency furnishing the report.I also authorize American Express to use the reports from consumer reportting agencies for marketing and administrative purposes. I understand that upon American Express's approval of the application, the enity will be sent the Agreement.
Using your mouse and left clicking in the signature box below, please sign your name indicating your
acceptance of the terms of this contract and click the "Save Signature" button. After you have completed
the application, please click the "Submit" button below.
* By signing below, I indicate that I agree to the terms and conditions:

NOTE: It is okay if your signature appears different than normal

** By Federal Law, All Information Provided Will Remain Confidential **

To begin accepting credit cards, click the submit button: