Mosaic Commerce: Merchant Account Application Form

This application form uses the latest 128-bit SSL encryption technology, so you can rest assured that your information is being handled in the safest manner

Doing Business As Name Company Legal Name (if different from DBA)

Location Address Mailing/Billing Address (if different from DBA)

City State
Zip Country
Phone - ext. Fax
Website
E-Mail

Merchant Profile

Business Open Date (i.e. 01/01/2000)
Expected Annual Sales ($US)
Federal Tax ID
Expected Average Sales ($US)
Type of Goods/Services
Sold Maximum Ticket ($US)

After submitting this form, an Alliance Bankcard Services, Inc. consultant will contact
you within 4 hours