VizyPay Merchant Application

Merchant Processing Application
Business Name*
Legal Business Name*
Business Address*

Street Address

Street Address Line 2

CityState

Zip Code
Billing Address (If Different)

Street Address

Street Address Line 2

CityState

Zip Code
Business Phone Number
Please enter a valid phone number.
Contact Name
Business Email
example@example.com
Contact Phone Number
Please enter a valid phone number.
Date Business Started

MonthDayYear
Date
Contact Email
example@example.com
Business Website Address
example@example.com
Business Structure

Individual/Sole PropC-CorpS-CorpLLCPartnership

Business Owner Information
Name

First NameLast Name
Title
% Ownership
SSN
Date of Birth

MonthDayYear
Date
Home Address

Street Address

Street Address Line 2

CityState

Zip Code
Mobile Phone
Please enter a valid phone number.
Email
example@example.com

Banking and Processing
Deposit Bank
Routing Number
Deposit Account

Voided Check

Cancelof
Drivers License

Cancelof
Signature

Clear
Date

MonthDayYear
Date
Should be Empty: