Coastal Vacations Merchant Account Application Form

Coastal Vacations Merchant Account Pre-Application Print, sign and fax to (281) 350-9220
FINANCING OPTIONS (Merchant account only)	$93.90 Monthly for 36 months (A-F Credit) $73.90 Monthly for 48 months (A-C Credit)
MERCHANT ACCOUNT OPTIONS	Electronic Terminal & Manual Imprinter Software Package Internet Real-Time
Business Name
Address
City
State		Zip
Phone		Fax
Email
Principal's Name
Home Address (if different from above)
City
State		Zip
Type of Business:	Sole Proprietor Partnership Corporation
Social Security #		Drivers license #
Bank Name
Bank Phone
Bank Account #		Contact
Signature:_______________________________ Date:__________________________ Merchant Authorizes Bank/Cardservice and affiliated leasing companies to check their credit with the utilization of the credit reporting agencies. Referring Director: (REQUIRED INFORMATION)
Name
Address
City
State		Zip
Phone
Mandatory: Director Information must be completed to be processed.