Merchant Heroes - PAYBOTX MPA V.T1

APPLICATION FOR MERCHANT CARD PROCESSING
Please name your sales representative*
Legal Name of Business*
(As filed to the state)
DBA Name
(Storefront Name)
Address*
City, State, Zip*
Phone Number*

Area CodePhone Number
Email Address for Notices*
example@example.com
Customer Service Phone Number*

Area CodePhone Number
Length Owned/ Years of operation*
Taxpayer Identification Number: Must be 9 digits (EIN or SSN)*
EIN for Corporation or LLC / SSN for Sole Proprietorship
Taxpayer Identification Number*

EINSocial Security Number
Legal Business Name (as shown on your income tax return)*
(Must match Legal Name, confirm be reviewing you EIN Letter)
Type of Ownership*

Sole ProprietorshipLLCPartnershipLtd Liability PartnershipCorporationNon Profit Corporation
Products or services sold*
Full name of owner (as shown on ID)*
Date of Birth*

MonthDayYear
Date
Percent Owned (%)*
Residential Address, City, State, Zip*
Home/Cell Phone Number*
Please enter a valid phone number.
Please upload a copy of your ID *

Cancelof
SSN*
U.S. Person Non-U.S. Person*

U.S. Person Non-U.S. Person
Title of person opening account *
(Manager, Owner, President)
Average Transaction Amount*
Example: $30, $50, $150, etc.
Total Monthly Sales*
Example: $50,000
Please provide a percentage of where the transaction method will take place. If E-commerce is selected, the business must have a website with a functioning shopping cart.
% of transactions Swiped/ In Person
1/3 Total of these three must equal 100 below
% of transactions key in Manually/ Phone
2/3 Total of these three must equal 100 below
% of transactions performed Online/Ecommerce
3/3 Total of these three must equal 100 below
This field must equal 100
Bank Name*
Routing Number*
Bank Account Number*
Please upload a copy of a voided check to verify banking information*

Cancelof
Merchant Signage
Date

MonthDayYear
Date
Signature (please ensure it matches the ID)*

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APPLICATION FOR MERCHANT CARD PROCESSING

Merchant Signage