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Paywire Merchant Application
Items in
*
are required
Company Name (DBA):
Business Address:
Business City:
Business State:
State...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
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Mississippi
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Montana
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Nevada
New Hampshire
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New York
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Ohio
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Rhode Island
South Carolina
South Dakota
Tennessee
Texas
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Vermont
Virginia
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West Virginia
Wisconsin
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Business Zip:
Business Phone:
*
Business Fax:
Email Address:
*
Contact Name (First/Last):
*
Title:
Description of products/services sold:
Are you currently accepting credit cards?:
Select One....
Yes
No
If you are currently processing, with which processor?:
Please select which type of account you will need:
Select One.....
Retail
Restaurant
Lodging
Mail Order/Telephone Order
E-commerce/Internet
Supermarket
Gas Station/Pay at Pump
Anticipated Visa/Mastercard monthly sales amount:
Average credit card sale amount:
Do you need recurring billing options? (ACH, EFT):
Select One...
Yes
No
Comments:
Please place any comments or question here....
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