Blaze USA Internet Services

Site Map

Contact

Portfolio

Services

Home

Internet Marketing · Web Development · Web Hosting · Server Colocation

Following is our Merchan Pre-Application form. Fill it out to the best of your ability and send it to our staff and one of our representatives will get back with you shortly.

Before Submitting this form we suggest that you print it for your recrods.
You may also fax it to (248) 673-2844

Services and Merchant Information

Legal Name of Business:
DBA : (if different than legal name):
Phone Number:
Business Fax Number:
Authorized Business Representative:
Title:
Address 1:
City:
State:
ZIP:
Country:
Web Site:
Email:

Mail Address (if different than above)

Address:
City:
State:
ZIP:
Country:

List Type of Business and Products/Services Sold (be specific):

Business Hours

Monday to Friday:	From: a.m. p.m. To: a.m. p.m.
Saturday:	From: a.m. p.m. To: a.m. p.m. Closed:
Sunday:	From: a.m. p.m. To: a.m. p.m. Closed:
Internet:	24 Hours:

Tax ID:
Age of Business:	Yrs. Mos.

OWNERSHIP
(51% ownership for corporation and 100% ownership for partnership/proprietorship,
MUST be on application)

Sole Proprietorship	Partnership
Private Corporation	L. L. C.

Principals Name:
Ownership %:
Title:
Date Of Birth:
Home Phone:
Social Security #:
Dirvers License:
Expiration Date:
Sate:
Street Address:
City:
State:
Zip:
Country:

Own Rent	How Long?

If Less Than Three Years At Above Address, Please Fill In Additional Address Information Below.

Street Address:
City:
State:
Zip:
Country:

Own Rent	How Long?

Name of nearest relative or friend not residing with you:
Telephone:
Street Address:
City:
State:
Zip:
Country:

Second Principals Name:
Ownership %:
Title:
Date Of Birth:
Home Phone:
Social Security #:
Dirvers License:
Expiration Date:
Sate:
Street Address:
City:
State:
Zip:
Country:

Own Rent	How Long?

If Less Than Three Years At Above Address, Please Fill In Additional Address Information Below.

Street Address:
City:
State:
Zip:
Country:

Own Rent	How Long?

References

DBA Bank Name:
Telephone:
Contact:
Trade Reference:
Telephone:
Contact:
Trade Reference:
Telephone:
Contact:

Marketing Method

Merchant Marketing Method By Percentage (Select All That Apply to Equal 100%)

Storefront	Service	Trade Show
Phone	Mail Order	Internet

Do you have a storefront?	YES NO
Homebased business?	YES NO

Advertising Methods

Newspaper Magazines Yellow Pages
Internet TV Radio Other

Average Sales Amount

Average monthly MasterCard/Visa volume:	(Best Estimate)
Average MasterCard/Visa ticket amount:	(Best Estimate)
Highest MasterCard/Visa ticket amount:	(Best Estimate)
Referred by:

Before Submitting this form we suggest that you print it for your recrods.
You may also fax it to(248) 673-2844

Contact Info
General Contact Form

Complete template-based web sites for only $399.95 - click here for more information

Request A Quote | Portfolio