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Now that you have decided to sign up for our Clover POS program please complete the below Merchant Application Worksheet. This form is used to gather the information necessary to complete your original Merchant Application. We will transfer the info that you provide to the original app and then fax or email it to you for your signature along with a checklist of any other items that might be required.

Business Information

Business Name (Doing Business As)

Corporate / Legal Name

Business Street Address

Business Phone Number

Business Fax Number

Business Email Address

Business Website

Type of Ownership:

State in which your company is registered:

Banking Information

Name of Bank

Bank Phone Number

Please either fax a blank voided check or signed bank letter to 215-489-7880 or scan and email to


Please let us know how many units you would like to order and any special information you think we may want to know. However, we will still speak with you in person to confirm all of the details.

Owner Information



Home Street Address

Home Phone Number

Mobile Phone Number

Date of Birth

Social Security Number -- will be asked verbally to protect your identity.

Percentage of Ownership (If less than 50% please repeat the above info for other individual in the Comments section).

Clover System Selected

Clover Station ($1299.00)
      Add FD40 Pin Pad (+$199.00)
      Add Impact Kitchen Printer (+$399.00)
      Add Bar Code Scanner (+165.00)
The monthly software fee is $39.00.

Clover Mini
      Wi-Fi Only ($449.00)
      Wi-Fi + 3g ($499.00)
      Add Cash Drawer (+$50.00)
The monthly software fee is $30.00 & the Monthly Wireless Fee (3g Only) is $15.00.

Clover Mobile
      Mobile Tablet + Printer + Docking Station ($799.00)
The monthly Software Fee is $30.00 & the Monthly Wireless Fee (SIM) is $15.00.

All above equipment prices include encryption, programming, installation, shipping and tax.

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