Choice Payment Services APPLICATION

APPLICATION FOR ENROLLMENT

Thank you for your interest in Choice Payment Services. If you have any questions you can contact us directly at enroll@choicepays.com
Primary Contact Information

Note that all information is required for lender onboarding, vetting and setup. Incomplete or inaccurate information may delay the approval process.
Full Legal Business Name*
Registered DBA Name.
If different than Legal Business Sole/Proprietor Name. If multiple DBA please elaborate in box provided below.
Primary Physical Corporate Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Point Of Contact*

First NameLast Name
Primary Contact Email*
example@example.com
Primary Contact Phone Number*
Please enter a valid phone number.
Number of Locations*
Industry / Specialty Focus of your Business*
Web Site Address*
Country / States of Operation*
You may include additional DBAs or other considerations as appropriate.
How did you hear about us?*

Official Business Entity Data

Information required to review and onboard your business entity.
IRS Filing Name*
Name of company as filed under IRS if different than legal business or sole proprietor name.
Federal Tax ID*
Years Operating Under Legal Name
State of Organization
Number of Employees*
Please provide a valid medical license number (dental / medical only)
Please provide details for all principals owning over 20%.
If you are a subsidiary or franchise location of a parent company, please identify:

Principal Authorized Ownership & Finance Information

Information needed for finance consultation, onboarding and preparation of customized programs. Please note that this information is necessary for vetting and ensuring accurate ownership and authorized representation of your company. Our compliance and legal processes ensure continuity and security for both our business and yours. If you have any questions about this information please contact us at enroll@choicepays.com
Principal Full Legal Name*
Principal Title*
Principal Date Of Birth*

MonthDayYear
Date
Principal SSN
This is needed for compliance and security but you may contact us to give over the phone if you prefer.
Please describe your current finance/lender setup, including names of companies used for primary, secondary & other finance.*
Please include lender names & technology used of applicable.
Finance Needs Summary*
Please share any challenges or needs so we can focus on supporting a comprehensive solution design.
Annual Sales Volume*
Annual Financed Volume*
Average Desired Financed Loan Amount*
Is your company or its parent company currently subject to any lawsuits or regulatory action? If yes please explain.*
Authorized Signature*

Powered by Jotform SignClear

Document Uploads Page

For your convenience, this page provides a single location to upload all the necessary documents. Please note that delay of any of these documents will slow down your enrollment process!
Please attach a copy of your business License.*

If you have multiple locations, please upload all of them here!
Cancelof
Please attach a copy of your executed W9*

https://www.irs.gov/pub/irs-pdf/fw9.pdf
Cancelof
Please attach an image of the Driver's License of the primary signatory.*

Cancelof
Please attach a copy of your refund/cancellation policy if applicable.

Cancelof
Primary Bank Name, Address(es)
Please attach copies of voided checks for all locations that will need to receive deposits. As an alternative you may also provide bank letters, including account holder Name, Address, Routing #, Acct #, Signed by bank representative with contact info for verification.*

Voided checks or bank letters are necessary to validate that the deposit information is accurate and authorized for business entity deposit. This helps prevent fraud and eliminate errors in deposit of your funds.
Cancelof
Person to contact for questions on any of these uploads:*
Please let us know if you have any other questions, comments or requests!*
We look forward to serving your needs!
Should be Empty:

Primary Contact Information