Meritum USA Pre-application Form.
Please complete the following form to pre-apply for merchant services with Meritum USA.

* indicates a required field
Store Name * Owner's Name *
Location Address City
State Zip
E-mail Address * Telephone (000-000-0000) *
Website Address Type of Owner
LLC Sole Proprietorship
Partnership Corporation
If Incorporated, Corporate Name
Billing Address City
State Zip
Date Business Opened Number of Locations
Federal Tax ID Description of Services or Merchandise Sold
Name of Owner/Officer #1 Title
SSN Credit
Excellent Good Avg Poor
DLN Expiration Date
Date of Birth Home
Own Rent
Length at Address Home Address
Name of Owner/Officer #2 Title
SSN Credit
Excellent Good Avg Poor
DLN Expiration Date
Date of Birth Home
Own Rent
Length at Address Home Address
Name of Primary Contact Person Title
Business Telephone Fax
Description of Premises Building Type
Store Front Office Bldg Own Rent
Residence Other
Landlord Name Landlord Phone

Applicant hereby certifies that the above is true, correct and complete and authorizes Meritum USA to investigate the information contained herein.
Your NAME is your Signature * Title

(800) 431-9848



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