EmeraldPay's Cash Discount MPA

Business Information
Business DBA (Doing Business As) Name*
Business Legal/Corporate Name*
Your Business Address (No P.O. Boxes)*

Street Address

Street Address Line 2

CityState

Zip Code
Is your business billing/corporate address different from the business' address?*

YesNo
Your Business Billing/Corporate Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Business Phone Number*
Please enter a valid phone number.
Your Business Email*
example@example.com
Your Business Website*
Your Business Start Date*

MonthDayYear
Date
Your Business' Entity Type*

Limited Liability Company/LLCCorporation - Chapter S/CIndividual/Sole ProprietorshipTax Exempt Organization (501c)Medical or Legal CorporationPartnership
State of Formation*
Name (as it appears on your income tax return)*
Federal Tax ID # (as it appears in your income tax return)*
Products/Services Sold*

Banking/Financial Information
Banking Information
Bank Name*
Routing Number*
Account Number*
Financial Information
Gross Yearly Sales Volume (Cash + Credit + Debit + Check) *
Yearly Visa/Mastercard Volume*
Yearly Discover Volume*
Yearly American Express Volume*
Average Ticket Amount*
Highest Ticket Amount*
Where are your sales transacted?

Total of all three questions should equal 100%. These can be rough estimates and do not have to be exact. (example 90% Swiped, 10% Keyed, 0% E-Commerce)
How much transactions are Swiped? (swiping the customer's card or using the chip reader)*
How much transactions are Keyed? (invoices, someone in your business "punching in" the card information into a terminal or gateway)
How much transactions are E-Commerce? (customer entering their credit/debit card information online through your website or shopping cart)
Percentage Total (Must Equal 100)

Additional Documents and Signature
Additional Documentation

Voided Check or Bank Letter required. Starter checks will not be accepted. A bank letter must have a bank letterhead, the company's name, routing number, bank account number, and signature from a bank representative.
Voided Check or Bank Letter*

Cancelof
First Owner's/Signer's Driver's License*

Cancelof
Signature and Initials
Initial Here*

Clear
Signature*

Clear
Signing Date

MonthDayYear
Date
Swiped %
Telephone Order %
Internet %
Equipment 1
Equipment 2
Equipment 3
Unit Price 1
Unit Price 2
Unit Price 3
Lease Term
Total Monthly Charge
Should be Empty:

Primary Contact's Information