Traditional Business- New Merchant Form
Agent Name
Business Legal Information
Business Legal Name
*
Entity Type
*
Please Select
Sole Prop
LLC
Corporation
Partnership
Legal Address
*
Legal City
*
Legal State
*
Legal Zip Code
*
Legal Phone Number
*
Federal Tax ID (EIN)
*
Legal Email Address
*
Business License
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Business Information
DBA Name
*
Business Address
*
Business City
*
Business State
*
Business Zip Code
*
Business Start Date
*
Business Phone Number
*
Business Email- If Different
Website
*
Products & Services Sold
*
Industry Type
*
Do you sell your products using e-commerce or retail?
*
If e-commerce, what platform is your website built on? *If not e-commerce, please mark with NA
*
*If not e-commerce, please mark with NA
What is your refund policy?
*
Please include how many days. *If not e-commerce, please mark with NA
Owner Information
Owner Title
*
Owner Full Name
*
Home Address
*
Owner City
*
Owner State
*
Owner Zip Code
*
Years at Address
*
Owner Cell Phone
*
Email Address
*
Owner Social Security #
*
Owner Drivers License Number
*
Owner Drivers License State
*
Owner DOB
*
% Ownership
*
Drivers License Front
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Drivers License Back
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2nd Owner Information
Owner Title
Owner Full Name
Home Address
Owner City
Owner State
Owner Zip Code
Years at Address
Owner Cell Phone
Owner Social Security #
Email Address
Owner Drivers License Number
Owner Drivers License State
Owner DOB
% Ownership
Drivers License Front
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Drivers License Back
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Financial Information
Has your business ever accepted credit or debit cards?
Please Select
Yes $0 to $20K per month
Yes $21k to $49K per month
Yes $50K+ per month
No- new business
Credit and Debit Card Yearly Volume
*
Avg. Ticket
*
Highest ticket your business will run
*
% Swiped in person at business
*
% E-Commerce
*
Bank Name
*
Name on Checking Account
*
Check Account #
*
Right Side of the Check
Check Routing #
*
Left Side of the Check
Voided Check or Bank Letter
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Bank Letters must be on bank letter head, state you have an open account and include banking information.
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Equipment/ Other
Do you need a Point of Sale system? If so, how many stations?
*
Do you need a standard terminal? If so, how many stations?
*
Do you want us to set up auto batch?
Please Select
Yes
No
Auto Batch Time
Do you need to be set up to accept tips?
Please Select
Yes
No
Do you need individualized tips by person?
Please Select
Yes
No
EBT #
Special Instructions
Large Volume Clients
$200K monthly volume or Average tickets over $10k
Sample Invoice
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3 Months Consecutive Bank Statements
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3 Months Consecutive Merchant Processing Statements
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2 Year Tax Returns
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