Application Form
This form is to collect information for WastePay to pre-fill your application and send it to you ready to review and sign.
Merchant Information
Legal Name
DBA Name
Only if different than Legal
Website
Organization Phone
-
Area Code
Phone Number
Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Legal Mailing Address (if different)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Organization Sturcture
*
Corporation
LLC
LLP
Non-Profit
Partnership
Sole Proprietor
Publicly Traded
Other
Date Formed
*
Federal Tax ID#/ EIN
*
Types of Services offered to public
*
Primary Contact
Person we can contact for any billing, application or administrative questions
Primary Contact
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Title
Email
example@example.com
Principals
Officers/Principal Name
*
First Name
Last Name
Percentage Ownership
Officers/ Principal Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Officer Date of Birth
*
-
Month
-
Day
Year
Date
SSN
*
Length of Ownership
Years and months
Are there other officers who own over 25%
*
Yes
No
Officer/Principal Name #2
First Name
Last Name
Percentage Ownership
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Officer Date of Birth
-
Month
-
Day
Year
Date
SSN
*
Length of Ownership
Years and months
Banking Infomation
Information to make sure you donations end up in correct account
Bank Name:
*
Account Type:
*
Checking
Savings
Routing Number:
*
Account Number
*
Financial Information
Company Annual Revenue ($)
Projected Monthly Card Sales ($)
Average Transaction Amount ($)
Highest Average Ticket ($)
Frequency of High Ticket (per year)
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Submit
Should be Empty: