MERCURY^®ACCOUNT REGISTRATION

FOR CREDIT CARD PROCESSING SERVICES

Please note: The personal information you supply will be used for the purpose of qualifying this merchant account by Mercury. This information is held in the strictest confidence and is never sold, rented, or shared with any other business or third party.

First Name:

Last Name:

Company Name:

Phone Number:

Email Address:

Address:

City:

State:

Postal Code:

Business Type:

Is this a new or existing business?

Current Processor:

Comments:

MERCURY® ACCOUNT REGISTRATION

FOR CREDIT CARD PROCESSING SERVICES

MERCURY^®ACCOUNT REGISTRATION