Cannabis- New Merchant Cover Sheet
Agent Name
*
Business Legal Information
Legal Name
*
Entity Type
*
Please Select
Sole Prop
LLC
Corporation
Other
Entity Other
Legal Address
*
Legal City
*
Legal State
*
Legal Zip Code
*
Legal Phone Number
*
Federal Tax ID (EIN)
*
Legal Email Address
*
Customer Service Email Address
*
Business Information
DBA Name
*
Business Address
*
Business City
*
Business State
*
Business Zip Code
*
Business Start Date
*
Business Phone Number
*
Business Email- If Different
Website
*
Program Set Up
$3.50 service fee- Zero Fees
Please Select
Yes
No
$4.00 service fee- Zero Fees with $.50 kick back to you
Please Select
Yes
No
Marijuana License Number
Owner Information
Owner 1
Owner Title
*
Owner %
*
Owner Full Name
*
Email
example@example.com
Home Address
*
Owner City
*
Owner State
*
Owner Zip Code
*
Years at Address
*
Owner Cell Phone
*
Social Security #
*
Owner Drivers License Number
*
Owner Drivers License State
*
Owner DOB
*
Owner 2
Owner Title
Owner %
Owner Full Name
Email
example@example.com
Home Address
Owner City
Owner State
Owner Zip Code
Years at Address
Owner Cell Phone
Social Security #
Owner Drivers License Number
Owner Drivers License State
Owner DOB
Owner 3
Owner Title
Owner %
Owner Full Name
Email
example@example.com
Home Address
Owner City
Owner State
Owner Zip Code
Years at Address
Owner Cell Phone
Social Security #
Owner Drivers License Number
Owner Drivers License State
Owner DOB
Financial Information
Are we providing you with a Cannabis Checking Account?
Please Select
Yes
No
If you have cannabis checking, please fill out the 3 questions below or add NA if signing up for Cultivates Cannabis Checking Account.
Bank Name
*
Check Account #
*
Right Side of the Check
Check Routing #
*
Left Side of the Check
Equipment/ Other
# Terminals
*
Connection Type
*
Please Select
Ethernet
Wifi
4G
Auto Batch
*
Please Select
Yes
No
Auto Batch Time
Special Instructions
*
Copy of Check
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of
Marijuana Business License
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Picture of Drivers License Front
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Picture of Drivers License Back
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Owner 2 Drivers License Front
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of
Owner 3 Drivers License Front
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of
Owner 2 Drivers License Back
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of
Owner 3 Drivers License Back
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of
Submit
Should be Empty: