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Merchant Registration
I. Correspondence & Communication Background (Information WILL NOT be shared with Sales Representative without your acknowledgement)
Account Information
Corporate Name Owner's First Name Owner's Last Name
Password Confirm Password
Password Hint Question Password Hint Answer
Mother's Maiden Name Confirm Mother's Maiden Name
Mother's Maiden Name
Hint Question
Mother's Maiden Name Hint Answer
Business Information
DBA Name of Business E-Mail Business Telephone No. - -
Business Address
City Business Cell No. - -
State Business Fax No - -
Country Code Employer Identification Number (EIN) or Social Security Number
(Will only be shared upon you selecting Top Bids)
Are you able to Terminate your Merchant Agreement with No Early Termination Fees?
Website Address If we (eQuotz® Only) need to contact you, When is the best time of day to reach you?
Hour  Min 
Would you like to apply for
a Business Credit Card?
Do you outsource your payroll processing? Who Provides your Local & Long Distance Phone Service?
II. General Background Information
Business Status Is this a retail location, i.e. Customers physically purchase goods & service at this location?
Business Description In how many locations do you operate?   Year established
Years in business for current ownership?   Number of employees  
Credit rating (Check all that applies)
Have you or your partners ever filed bankruptcy? Do you have any open   liens or judgments? Do you have any current delinquencies? Have you had delinquent payments in the   past two years? Does the business have a negative cash flow?
Description of products or services offered to consumers
Visa & MasterCard American Express PIN Based Debit Discover Diners JCB Electronic Checks Gift Cards Electronic Benefit (EBT)
Do you Currently Accept:
Do You Wish to Accept:
Who is Current Processor (Whose Name appears on your Merchant Statement)(If other please enter)
How long have you been processing with the bank? Years   Are you able to Terminate your Merchant Agreement with
No Early Termination Fees?
Reason for evaluating a new relationship:
(Please rank each category with a value between 1 - 8. Don't duplicate and 8 is the highest # for looking for a relationship)
Lack of
(Training /
Software Problems
Difficult to
Require a more
Competitive Rate
Funding Delays Poor
Customer &
Difficult to
Daily Reports
System Uptime
& Reliability
are Issues
III. Credit Card Information
What percentage of cards are
physically present at time of sale?
%   What percentage of transactions are
generated from Mail & Telephone?
%   What percentage of transactions
are generated from the Internet?
What type of point of sale equipment are you currently using? Stationary Terminal         Mobile/Wireless Terminal         PC/LAN Software 
What level of security is/will be used? Check all that apply. EMV       Tokenization       P2P (Point to Point Encryption)       PCI Certification  
What type of Point Sale Device do you use?
(If Others Please Enter)
What is the name of the software you use?
(if Others Please Enter name of the Software)
What percentage of your Credit Card
transactions are generated from?
% Purchase Cards   % Commercial Cards   % Business Cards  
Select Monetary Code
SIC Code & Business Description
Annual Business Revenues / Sales $
If you are a restaurant do you want
Do you want the ability to collect tips? Do you wish to offer Cash Back to your
Customers on Debit Transaction?
Total Monthly Credit Card "Sales" Volume (Visa & M.C. Only) $ Average Ticket Size $
(Amend Data If Necessary)
Classic Cards
Check Cards Consumer Classic
World Cards
Check Card Rewards/
World Cards
Total Cards Amex Consumer Classic Cards Amex CheckCards Signature Debit Amex Consumer Classic Rewards /World Cards Amex Check Card Rewards /World Cards Amex Total Cards Discover Consumer Classic Cards Discover CheckCards Signature Debit Discover Consumer Classic Rewards /World Cards Discover Check Card Rewards /World Cards Discover Total Cards Check PIN Debit
Total Monthly
"Sales" Volume (VP)
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
Average Ticket Size(AT) $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
Total Monthly(TM)
"Transaction" Volume
Monthly Dollar Volume that  will
downgrade to "Partial Qualified"(VPQ)
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $    
Monthly Dollar Volume that will
downgrade to "Non
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $    
Percentage Returns / Exchanges / Credits(PR) % Chargeback Percentage %
Total Number of ARU Authorizations Inquiries for Visa & M.C - Consumer Credit- (CP) Enter What is the Total Number of ARU Authorizations Inquiries for Visa & M.C. - Check Cards (Signature Debit)
IV. Auction Options
How long do you want the bidding window to remain open?
Exclude Settlement Bank Exclude MSP Exclude Processor
Do You wish to exclude any Settlement Bank, MSP, or  Processor from being able to view & submit a bid?(To Select Multiple Items press 'Ctrl' and 'Left Mouse click' on the item)
Do you require the Sales Representative to be within a 25 mile geographic proximity to your location? Would you allow eQuotz ® to use you as a referral? Would you allow eQuotz ® to use your Testimonial?
eQuotz® Disclaimer
Notice to users of the eQuotz® service: eQuotz®, its owners, employees, officers and directors are not responsible or liable for the services provided as a part of this website. The Website is to bring together merchants and acquirers for prospective business arrangements. Accordingly, eQuotz® is not responsible for the information related to any merchant or acquirer, for any quotes or subsequent pricing or for the quality of any services provided by any subscriber or user of the eQuotz® website, either merchant or acquirer. Use of this site constitutes the agreement of the user to deal with the acquirer and to hold eQuotz®, its officers, directors and employees harmless from any claims of any nature whatsoever.
Thank You
We certainly appreciate you taking the time to visit and use the eQuotz® product. We are confident this experience will save you money and improve the quality of your merchant account processing. If you agree with us, we would be very grateful if you would pass along the eQuotz® name as a referral to one of your business associates. However, if you feel that we did not completely meet your expectation, we want to hear about it help@equotz.com. Again, thank you for Your business!