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Express Application

Business Information:

Business Name:
City, State, Zip        
Country: Currently accepting applications for US ONLY
Telephone Number:
Fax Number:

Business Details:

Type of Ownership:
Percent Mail Order/Internet
Percent Phone Order
Is your business product or service based?  Product  Service Both
Explain the type of product or service you provide:
Amount of Average Sale:
Estimated Monthly Volume:
Web Site (URL):
Do you currently have Merchant status with any bank?  Yes  No

Contact Information:

First Name:
Last Name:
Home Street Address:
City, State, Zip:
Country: Currently accepting applications for US ONLY
Email Address:
Date of Birth: mm/dd/yy:
Best Contact Phone:
Best Time To Reach:
Percent Equity Ownership:
How would you rate your credit?

Credit Card Processing Options:

How would you prefer to process your customers' Credit Cards? Standand Credit Card Terminal
PC Software
Macintosh Software
For Details On Real-Time Internet Credit Card Processing Click Here

Other Questions:

How soon would you like to get set up with a merchant account?
Will your product be downloadable from the Internet? Yes  No
Are you operating through a drop-ship company? Yes  No
What additional services would you like information on? Domain Name Registration
Web Site Hosting
Shopping Cart Software For Your Website
Graphic Design & Web Development

How were you referred to AIS?   For example, which particular Web Page, Newsgroup, or Search Engine brought you here?

If you have any additional comments or questions please enter them here.

Please submit this application only once.  Multiple submissions may cause an error in our system and cause your application to be deleted.


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