Indyhost.Net's Merchant Application
Personal information or e-mail addresses collected on our online application form are confidential and will be used only for the purpose of processing your application.

 Company Information

Business Name

Physical Business Address

City

State

Zip Code

Contact Person

Office Telephone Number

Fax Number

 Please Tell Us About Your Business

Type of Business

Type of Merchant

Website Address

Email Address

 Credit Card Processing Needs

Average Ticket Size

Monthly Credit Card Volume

Equipment / Service Needs -
If you have existing equipment please describe below.
If buying equipment from our online store, your selection is filled in automatically.

New Equipment


We sell and support additional equipment. If your desired equipment is not listed, or you are not sure, select 'Other' and we can discuss your needs further.

Existing Equipment

Pin Pads & Check Readers

Wireless

Software

Internet / Web Site

I may need help designing my new Web site

 Ownership Information

Owner Name

Business Entity

Owner Home Address

City

State

Zip Code

Home Phone

Other

Purchase Options

How did you hear about us?

Sales Rep Name

Special Instructions?

    

 


 

 

Get 10% Off Credit Card Machines and Equipment*
if you complete this application and purchase a terminal on the same day!

* Discount will be given as a refund to your merchant account after you sign up and are approved for processing services
Indyhost.Net is a registered ISO in association with Columbus Bank and Trust Company, Columbus, GA.