Pre-Qualify - Empyrean Merchant Services

PRE -

QUALIFY

Promo Code
Legal Name
DBA/Outlet Name*
Contact Name
Business Phone Number
Type of Business
Corporate Address
Street Address City State / Province / Region ZIP / Postal Code Country
DBA Mailing Address (if different from above)
Street Address City State / Province / Region ZIP / Postal Code Country
Email*
Website
Business start date
MM slash DD slash YYYY
HST Number
Business Summary:
Please provide a brief summary of your core service and/or product

First Principal
First Middle Last
Title
Social Insurance Number
Date of Birth (mm/dd/yy)
MM slash DD slash YYYY
Phone
% Ownership
Home Address
Street Address City State / Province / Region ZIP / Postal Code Country
Choose processing category*
Enter MOTO/Internet sales %*
Enter Chip & Pin transactions %*
POS type (Terminal model)*
Rent/Lease/Purchase*
Price*
Notes About the Terminal
Visa Monthly Volume*
MasterCard Monthly Volume*
Average Credit Transaction Size*
All Cash & Card Sales*
Visa Credit*
Per transaction*
Visa Debit*
Per transaction*
Visa Card Brand Fee*
Mastercard Credit*
Per transaction*
Mastercard Debit*
Per transaction*
MC Card Brand Fee*
Per transaction*
Discover/Diners*
Per transaction*
UPI Debit*
Per transaction*
Please choose following:
- Interac Debit
- Interac Flash Opt IN
Add Second Principle?
- Yes
Second Principal
First Middle Last
Title
Social Insurance Number
Date of Birth (mm/dd/yy)
MM slash DD slash YYYY
Phone
% Ownership
Home Address
Street Address City State / Province / Region ZIP / Postal Code Country
Attach Driver’s Licence
Max. file size: 516 MB.
Attach Void Cheque
Max. file size: 516 MB.
Attach Articles Of Incorporation
Max. file size: 516 MB.
Attach Processing Statements
Drop files here or

Max. file size: 516 MB.
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