"American Express"

Apply for Your Business to Accept the Card In order to process your Application please provide the following information on the electronic application. All mandatory information is highlighted in BOLD. An American Express representative will contact you to confirm your application and request any additional documentation.

	For further assistance or questions please contact American Express, from Monday to Friday, 9:00am to 5:00pm at:
	Toll Free Number: 1 800 AXP AMEX(297 2639) CHOOSE LANGUAGE AND PRESS 3 FOR AFILIATIONS
	FAX: 1-787 474 3215


	Name of primary contact:

	Telephone number for primary contact person: (Please include country code)	ext.

	Best time to call:

	Additional phone number:

	I would like to accept card at:	One location Multiple locations in the same industry Multiple locations in different industries

	Name of Business:

	Physical Address/Location for Business:

	City:

	State:

	Zip Code:

	Country:

	Check here if mailing address is same as above. If not, fill in the fields below.

	Business Mailing Address:

	City:

	State:

	Zip Code:

	Country:

	Fax Number for business (Please include country code):	Enter in format 9999999999 - no spaces, no dashes

	E-mail Address for business:
	By Providing your e-mail address you permit and authorize American Express to notify you or your business of products, services and offers. Please be advised that we can only accept e-mail addresses up to 39 characters. Please consult our privacy and confidentiality guidelines for further information.

	Business Web Site Address(URL):	Enter in format http://www.yourcompany.com

	Most of my business is conducted:	In Person Through Mail-Order/Phone Over the Internet

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