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Please review the information carefully before submitting.
BUSINESS OWNER'S NAME: *
First Name
Last Name
Email:
*
example@example.com
Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
DATE OF BIRTH:
*
SSN: ( If Applicable)
DRIVER'S LICENSE NO. : (If Applicable)
PREFERRED CONTACT METHOD:
Call
Email
Text
Text and Email
BUSINESS INFORMATION
COMPANY LEGAL NAME:
*
DBA ( Doing Business as Usual ):
*
COMPANY EMAIL:
*
example@example.com
COMPANY PHONE NUMBER:
*
Please enter a valid phone number.
Format: (000) 000-0000.
COMPANY ADDRESS:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
BUSINESS BANK ACCOUNT NUMBER:
*
BANK ACCOUNT ROUTING NUMBER:
*
BUSINESS TAX ID/ EIN#:
*
COMPANY WEBSITE URL:
*
EX: www.website.com
IS THE WEBSITE ACTIVE:
YES
NO
IN PROCESS
NUMBER OF PRINCIPAL OWNERS:
BILLING MODEL:
*
ONE TIME PAYMENT
SUBSCRIPTION/ MEMBERSHIP
OTHERS
BUSINESS STRUCTIRE
SOLE PROPRIETORSHIP
LLC
GOVERNMENT
NON PROFIT
PUBLIC CORPORATION
PARTNERSHIP
CORPORATION
PROCESSING HISTORY
Has the business or any of the principals had a merchant account terminated or placed on TMF/MATCH list?
*
YES
NO
Has the business or any of the principals had ever filed for Bankruptcy?
*
YES
NO
If Yes, When and was it personal or Business ?
AVERAGE SALE AMOUNT:
*
Round to the nearest whole number (no $ or commas, or periods)
CURRENT MONTHLY PROCESSING VOLUME: *
HIGHEST SALE AMOUNT:
*
Round to the nearest whole number (no $ or commas, or periods)
UPLOAD REQUIRED DOCUMENTS
EIN#:
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CLIENT AGREEMENT:
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BANK STATEMENTS: ( UPLOAD ALL 3 MONTHS)
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MERCHANT ACCOUNT STATEMENT: (If Applicable)
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VOIDED CHECK COPY / BANK LETTER:
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GOVERNMENT ISSUED ID:
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ARTICLES OF INCORPORATION: (If Applicable)
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Submit
Should be Empty: