Merchant Account Application

Thank you for your interest in American Dynamic Data Solutions and our merchant services programs.
Please fill out and submit the pre-application form below. A sales representative will contact you within 24 hours.

Merchant Name/DBA:*

Owner's First Name:*

Owner's Last Name:*

Mailing Address:*

City:*

State:*AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

Currently accept credit cards?:   Yes No

Where did you hear about us?:

*marks required fields

Business Phone:*

Alternate Phone:

Best time to contact:

Fax:

Email:*

Zip:*

Previously taken credit cards?:   Yes No

Which products or services interest you?: