The Borek Group Business Registration Form

Register Your Business

Please provide all required details for your merchant account set-up.
DBA Name*
DBA Address (No PO Box)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Website
Country of Primary Business Operations*
Length of Current Ownership*
Years and Months
Established Year*
Business Country of Formation*
Does company have the ability to issue bearer shares as ownership stake in the company? (Required if country of formation is outside of the U.S.)
Contact Name (If different from Principal)

First NameLast Name
Contact Phone Number

Area CodePhone Number
Contact Email
DBA Fax

Area CodePhone Number
TIN (Employer Id #)*
Type of Business*
If You Chose LLC - Please choose a tax classification:*

D (Disregarded Entity)C (C Corporation)S (S Corporation)P (Partnership)
Tax Exempt Organizations Must Submit Supporting Documents

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Legal Business Name

Principal Information

INCLUDE ALL ADDITIONAL OWNERS WITH 25% OR GREATER OWNERSHIP
Percentage of Ownership*
%
Is there more than one principal owner?*
Type of Ownership*

Sole ProprietorAuthorized Signer
Principal Owner 1*

First NameMiddle NameLast Name
Principal Owner 2*

First NameMiddle NameLast Name
There are More Than Two Principal Owners*
* You may provide additional owner information later
Home Address (No PO Box)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous Home Address (If at last home address less than two years)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Social Security Number*
Other Country Issued ID #
If Other ID#: Country of Issuance
If Other Government Issued ID Name

Bank Information
Deposit Bank Name*
DDA Account Number*
Billing Chargeback Bank Name (If Different)
ABA/Routing Number
DDA Account Number
Additional Information
Average Sale Amount*
Highest Sale Amount*
Number of High Sales Annually*
Total Monthly Visa/Mastercard/Amex/Discover/Unionpay Sales *
Total Annual Revenue *
Percentage of Card Present Credit Card Transactions %
Percentage of Card Not Present Transactions (phone or mail)%
Percentage of Internet Transactions%
Funding Option- How quickly would you like to be funded?*

Default/Standard (48-72 business hours)Next Day Funding (next business day $5.00/mo)Fast Track Funding (same business day $7.50/mo)
Fee Options: How would you like to pay for fees incurred?*

Daily Discount: Fees are deducted daily/every time you are funded.Monthly: All the money you collect is funded to you and all fees are deducted as a lump sum at the end of the month.
Should be Empty:

Register Your Business