Merchant Services Application

Applicant must be a resident of the state of Pennsylvania.

Online Merchant Services Application
You must have an existing, or be willing to open, a QNB Bank business checking account to apply.
Company Information
Corporate Name:  
Trade Name:  
Federal Tax ID#:  
State Issued:  
County:  
Work Phone Number: ( ) -
Contact Person:
Email:
   
Street Address
City, State: ,
Zip:
   
Mailing Address:
City:
State:
Zip:
Type of Business:
   
Confidential Personal Data
(1) Principal Name:
(First M. Last)
Home Address:  
City, State: ,
Zip:
Home Phone Number: ( ) -
SSN:
Date of Birth:
(MM/DD/YYYY)
/ /
Position:
   
(2) Principal Name:
(First M. Last)
Home Address:
City, State: ,
Zip:
Home Phone Number: ( ) -
SSN:
Date of Birth:
(MM/DD/YYYY)
/ /
Position:
   
Account Type
Ownership is: Sole Proprietor
Own/Rent:
Number of Locations:  
Years There:  
Monthly Bankcard Sales Volume (EST):  
Average Ticket:  
Are you currently accepting credit cards now?:
   
Credit Disclosures
Upon submission of this online application, I/we hereby authorize the Bank to make whatever inquiries it deems necessary in connection with my/our merchant application. I/We certify the above statements made in connection with this application are true and correct. Any false or misleading statements could lead to termination of this agreement. This form is not to be construed as an acceptance to your request.