Merchant Services Application Form

Step 1 of 6 - Eligibility and Account Type

Eligibility

Indicate your eligibility for membership.

How Do You Qualify For Membership with Your NC Community Credit Union?*

I am a CURRENT MEMBER

My business is located in or operates in Wayne County, NC

I LIVE in Wayne County, NC

I WORK in Wayne County, NC

I WORSHIP in Wayne County, NC

I ATTEND SCHOOL in Wayne County, NC

I do ONE OR MORE of the above

How Did You Hear About Us?*

Payment Processing Information

Gateway/Terminal To Be Used*

Annual Gross Sales (TOTAL)

Annual Mastercard/Visa Sales

Average Ticket

Do You Wish to Accept American Express Cards?*

Yes

Routing Number*

Account Number*

Principal #1 Information

Principal #1 Name*

First Middle Last Suffix

A Principal for your account is anyone authorized to complete transactions on behalf of the business.

Principal #1 Position within Company*

Principal #1 %age Ownership*

Principal #1 Social Security #*

Principal #1 Home Address*

Street Address Address Line 2 City State ZIP Code

Principal #1 Home Phone*

Principal #1 Cell Phone*

Principal #1 Work Phone*

Principal #1 Email Address*

Enter Email Confirm Email

Principal #2 Information (if you do not have a 2nd principal, SKIP this section)

Principal #2 Name

First Middle Last Suffix

Principal #2 Position within Company

Principal #2 %age Ownership

Principal #2 Social Security #

Principal #2 Home Address

Street Address Address Line 2 City State ZIP Code

Principal #2 Home Phone

Principal #2 Work Phone

Principal #2 Email Address

Enter Email Confirm Email

Certify Your Information

Authorization*

I/We agree

I/We do not agree

By checking "I Agree" above, I/we agree, on behalf of the Account Owner, that I/we authorize the release of the above information to a representative of NCCFCU for review by First Data, a vendor for merchant services processing.