ACH Sign Up Form
Business Information
Legal Name
*
DBA Name
*
Physical Address
*
Mailing Address
*
Primary Contact
*
Cell Phone
*
Email Address
*
Federal Tax ID (EIN)
*
Website URL
*
How long at physical address
*
Business Start Date
*
Do you currently accept ACH payments?
*
Please Select
Yes
No
Has your business ever been terminated by an ACH business?
*
Please Select
Yes
No
Business Days and Hours or Operation
*
Customer Service Number
*
Product/service Description
*
How long before products/ services delivered?
*
Please explain your return policy
*
Is a fulfillment center used?
*
Please Select
Yes
No
If yes, please provide there: name, email, phone number.
What is your average ticket?
*
What is your high ticket?
*
Average monthly volume?
*
Seasonal merchant? If yes, what months are you accepting ACH.
*
Voided Check
*
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Trade References
Bank Name
*
Bank Contact
*
Bank Contact Email
*
Bank Contact Phone Number
*
Bank Address
*
Bank Account Number
*
Bank Name
*
Reference 2
Bank Contact
*
Reference 2
Bank Contact Email
*
Reference 2
Bank Contact Phone Number
*
Reference 2
Bank Address
*
Reference 2
Bank Account Number
*
Reference 2
Owners Information
MUST EQUAL 100%
Owner 1 Full Name
*
Owner 1 Home Address
*
Owner 1 Cell Number
*
Owner 1 Social Security Number
*
Owner 1 Email
*
Owner 1 DOB
*
Owner 1 Title
*
Owner 1 Drivers License
*
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Owner 2 Full Name
Owner 2 Home Address
Owner 2 Cell Number
Owner 2 Social Security Number
Owner 2 Email
Owner 2 DOB
Owner 2 Title
Owner 2 Drivers License
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Owner 3 Full Name
Owner 3 Home Address
Owner 3 Cell Number
Owner 3 Social Security Number
Owner 3 Email
Owner 3 DOB
Owner 3 Title
Owner 3 Drivers License
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Owner 4 Full Name
Owner 4 Home Address
Owner 4 Cell Number
Owner 4 Social Security Number
Owner 4 Email
Owner 4 DOB
Owner 4 Title
Owner 4 Drivers License
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Required Documents
3 Months Company Bank Statements (if start up, 3 months personal)
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Articles of Incorporation
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3 Months ACH Processing Statements (if available)
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Submit
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