ATM Operator Agreement

ATM Operator Agreement
Select One:*

Applicant is an Individual Or a Sole ProprietorApplicant is a Company
Check Appropriate Applicant Role(s):*

ATM OperatorATM Source of Funds ProviderBoth ATM Operator and ATM Source of Funds Provider
Terminal Deployment Location
A registered location name and address are required for this Operating Agreement. If you don’t have a location yet, please use your business name and address (even if it’s your home) for now. The Operating agreement location doesn’t need to be changed once submitted even if you move or install the ATM at a different retail location as long as you’re the operator.
Location Name*
Location Address*

Street Address

Street Address Line 2

CityState

Zip Code
Contact Phone Number
Business Tax ID Number of Merchant
Type of Business (Sole Proprietor, Partnership, LLC, Corporation, Financial Institution)
Merchandise/Services Sold where terminal is deployed
Financial Institution Number (FI#, FDIC, NCUA, ASI)
Deployed Terminal Information
Terminal Identification Number
Processor of deployed terminal
Applicant is an Individual or a Sole Proprietor
Applicant Name

Applicant First NameApplicant Last Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Applicant Tax ID (Select Applicable Type)*

SSNSIN
Applicant Social Security Number*
Applicant Date of Birth*

MonthDayYear
Date
Applicant Home / Mobile Number*
Applicant is a Company
If you used your business name/address for the location the same information would be entered for your Company information below.
Company Legal Name
As stated on Articles of Incorporation
Company Address

Street Address

Street Address Line 2

CityState

Zip Code
Company Business Tax ID (FEIN) (Select Applicable )Type*

Business Tax IDSSNSIN
FEIN / TAX ID*
Company Date of Incorporation*

MonthDayYear
Date
Company State of Incorporation*

Street Address

Street Address Line 2

CityState

Zip Code
Entity Type*
PATRIOT ACT DISCLOSURE: IMPORTANT INFORMATION ABOUT PROCEDURES FOR BECOMING A CUSTOMER – To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each individual or entity who becomes a customer. What this means for you: When you become a customer, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver’s license or other identifying documents.
Name*
First & Last Name
Signature*

Clear
Title*
Date*

MonthDayYear
Should be Empty:

ATM Operator Agreement

Terminal Deployment Location

Deployed Terminal Information

Applicant is an Individual or a Sole Proprietor

Applicant is a Company