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: * Business Address Street: * City: * State: * Zip Code: * Mailing Address Street: * City: * State: * Zip code: * Type of Business: * Confidential Personal Data Principal 1 First Name: * M. Last Name: * Home Address: * City: * State: * Zip Code: * Home Phone Number: * SSN: * Date of Birth: * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017 Position: * Principal 2 First Name: M. Last Name: Home Address: City: State: Zip Code: Home Phone Number: SSN: Date of Birth: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20152016201720182019 Position: Account Type Ownership is: * Sole Proprietor Partnership Corporation Own/Rent: * Own Rent Number of Locations: * Years There: * Monthly Bankcard Sales Volume (EST): $ * Average Ticket: $ Are you currently accepting credit cards? * Yes No 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. Leave this field blank CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions. What code is in the image? * Enter the characters shown in the image.