Application Request Form

Application Request Form

This is not an official application. From this information, we will generate an application and send it back to you to for signing via online signature software. It is recommend to use a desktop computer while filling out this form. If you need this form emailed to you please reach out to your agent or email us: hi@altitudepayments.com
Business Corporate/Legal Name*
must match IRS tax filing
Business Name (DBA)*
Location Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Corporate Address (leave blank if same as location)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Location Phone*
Please enter a valid phone number.
Location Fax
If non leave blank.
Business Description*
Contact Name*

First NameLast Name
Contact Phone Number*
Please enter a valid phone number.
Business Email*
example@example.com
Business Website Address (if none leave blank)
www.website.com
Any Prior Security Breaches?*

YesNo
Multiple Locations?*

YesNo
Federal Tax ID (must match IRS filing)*
Send Retrieval/Chargeback Requests to:*

Corporate AddressLocation Address
Date Business Started*

MonthDayYear
Date
Length Current Ownership*
Years/Months
Business Type*

Sole PropPartnershipLLC/LLPC CorpS CorpGovt.501c/Tax Ex.Other
Send Monthly Merchant Statements to*

Corporate AddressLocation Address
Owner/Partner #1 Name*

First NameLast Name
Owner/Partner #1 Phone*
Please enter a valid phone number.
Owner/Partner #1 Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Owner/Partner #1 Email*
example@example.com
Owner/Partner #1 Birthdate*

MonthDayYear
Date
Owner/Partner #1 Percentage Ownership %*
example (50%)
Owner/Partner #1 Social Security Number*
Owner Drivers License (Front Only)*

(If you do not have available please leave blank)
Cancelof
You may leave the below section blank if no other owners exist.
Owner/Partner #2 Name

First NameLast Name
Owner/Partner #2 Phone

Area CodePhone Number
Owner/Partner #2 Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Owner/Partner #2 Email
example@example.com
Owner/Partner #2 Birthdate

MonthDayYear
Date
Owner/Partner #2 Percentage Ownership %
example (50%)
Owner/Partner #2 Social Security Number
Owner Drivers License (Front Only)

(If you do not have available please leave blank)
Cancelof
You may leave the below section blank if no other owners exist.
Owner/Partner #3 Name

First NameLast Name
Owner/Partner #3 Phone
Please enter a valid phone number.
Owner/Partner #3 Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Owner/Partner #3 Email
example@example.com
Owner/Partner #3 Birthdate

MonthDayYear
Date
Owner/Partner #3 Percentage Ownership %
example (50%)
Owner/Partner #3 Social Security Number
Owner Drivers License (Front Only)

(If you do not have available please leave blank)
Cancelof
Business Type*

RetailRestaurantEcommerceAuto/Home WarrantyGovernmentLodgingSupermarketPetroleumUtilitesBeauty SalonMedical/HealthcareEducationQSRCharity/Non ProfitB2BPrinting ShopMarketingGamblingSmoke/VapeOther
Seasonal Merchant? (select the months your business is active. Or select the non-seasonal option)

JanFebMarAprMayJunJulAugSepOctNovDecNon-Seasonal (open all year)
Average Monthly Processing Amount*
ex: $50,000
Average Transaction Price*
(Average price transaction) ex: $49
Highest Transaction Price*
(Highest price transaction) ex: $500
Expected # of Highest Transaction Sales Yearly*
ex: 10 sales
Client Card is Present & Swiped %*
ex: 0%, 50%, 100%
Client Card is Present & Not Swiped %*
ex: 0%, 50%, 100%
MOTO (mail order/telephone) Sale %*
ex: 0%, 50%, 100%
Internet (eCommerce) Sale %*
ex: 0%, 50%, 100%
Sales to Consumers %*
ex: 0%, 50%, 100%
Sales to Business (b2b) %*
ex: 0%, 50%, 100%
Sales to Government*
ex: 0%, 50%, 100%
Days to Delivery (how long until customer receives product or service)*
ex: 2 business days
What is your current payment system setup? (pricing, system, company, etc.)*
ex: stripe, square
Description of products or services sold*
Briefly Describe Return Policy*
Which Program Are You Interested In?

Net Zero FeesLower Traditional FeesI’m Not Sure (need more info)
Who is your agent?
You may leave any of the below document sections blank if you do not have them available. Please contact your representative & email any documents you were not able to upload to (hi@altitudepayments.com) as soon as possible following your submission.
Most Recent Bank Statement*

Cancelof
Most Recent Processing Statement From Your Current Payment Processor*

Cancelof
Voided Check or Bank Letter (must match business deposit account below)*

Cancelof
Deposit Bank Routing Number*
Deposit Bank Account Number*
Fees/Chargeback Bank Account Number (leave blank if same as deposit)
Fees/Chargeback Bank Routing Number (leave blank if same as deposit)
By signing below you are stating that the above information is correct and accurate. This is not an official application. By signing, it will allow Altitude Payments to use this information in order to generate an application document on your behalf. Altitude will not submit any official applications until the final document is reviewed and signed by the majority owner(s). The official application document will be sent via email (DocuSign) within 2 business days after we receive your information.
Name*

First NameLast Name
Signature*

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