Business Name (DBA):

Existing Merchant ID#:

Business Address:
(no P.O. Boxes)         

City:     State:

Zip:

Ship statements to this address?  yes  no

Corporate E-mail:

Business Phone #:

Business Fax:

Location of Business:

Contact First Name:

Contact Last Name:

Enter your Corporate information if it is different than the business information you have already entered.

Corp. Name:

Corp. Address:

City:     State:

Zip:

Ship Statements to this address?  yes  no

Corp. Phone number:

Corp. Fax:

Contact First Name:

Contact Last Name:

Ownership Information

First Name:  

Last Name:

Social Security Number:

Title:

Phone #: 

% of Ownership:

Home Address:

Home City:

Home State:

Home Zip:

Date of Birth:

If ownership is less than 50%.  Please complete the following additional information for an additional an additional officer.

First Name:

Last Name:

Social Security Number:

Title:

Phone #:

% of Ownership:

Home Address: 
(No P. O. boxes)

Home City:

Home State:

Home Zip:

Date of Birth:

Business information

Year Established:

Length of Current Owner ship:   Years  Months

Do You Have Prior Experience?  Yes   No   Years

Service/Products:

Business Structure:

Federal Tax ID or SSN:

Current Bankcard Processor:

Have you or the business been involved in claims or lawsuits:  Yes   No 

Have you or the business ever declared bankruptcy?:  Yes   No

Card Present:  %
Mail Order: %
Telephone Order: %
Internet: %

Merchant Customer service phone #:

Average Credit Card Ticket: $
  (for online business only)
Monthly Credit Card Volume:  $$
  (for online business only)

Checking Account Number:
  (business account)

9 Digit Routing Number:

Apply for an American Express account in addition to MasterCard / Visa

  Yes   No  (American Express charge 3.5% MasterCard / Visa 2.35%)

Type of merchant (check applicable boxes):

Donation / Internet / Mail Order
Travel / Tour
Future Delivery

How long it takes for customers to receive goods/service:

Instant
Within 2-5 hours
Within 1-2 days
Within 2-4 days
Other   

Do you charge for goods/services prior to them being shipped?
          Yes   No

Are orders received and processed at your business location?
         Yes   No

Where is your Inventory stocked?

Who provides order fulfillment services?

What is your refund policy?

How do you provide customer service?

Please check your type of business:

Education   Non-profit   Auction     Other:  

Please check your billing methods:

          Monthly   Quarterly   Yearly
   
          One Time   Hourly   All Methods

Web Page Address: 

Server site location address:

Please list your major trade references / suppliers:

Please print and fax  (202-478-2880) or send to:

ZimmerWorks
Attn. Austin Zimmer
6101 Wilson Lane
Bethesda, MD 20817

Thank you!  ZimmerWorks will be in touch within 48-72 hours.  Call 301-365-8286, or email Austin@ZimmerWorks.com, with questions if necessary.