Merchant Information Form

Business Information
Legal Business Name *
DBA Name *
Business Website*
Business E-mail*
Business Phone Number*
Date Business Started

MonthDayYear
EIN Tax ID*
Business Type

Sole ProprietorshipLLCCorporation
Physical Business Address*

Street Address

CityState

Zip Code
Legal Mailing Address (If Different)

Street Address

CityState

Zip Code
Payment Processing Information
Services / Products Sold *
Refund Policy*
Monthly Total Sales Volume*
Average Per Sale Amount*
Highest Per Sale Amount*
Banking Information
Bank Name
Routing #*
Account #*
Voided Business Check or Bank Letter

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Owner Information
Full Name*

First NameLast Name
Email
Phone Number
SSN*
DOB*

MonthDayYear
Copy of Driver's License

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Should be Empty: