QleenPay App 5.42

Business Information

Our application is simple and only takes a few minutes to complete.
Legal Name of Business*
DBA*
Business Website*
Business Phone*

Business Address
Business Street Address*
Suite / Unit*
City*
State*
Zip*
Is your mailing address the same as your business address you entered above?

Yes, same addressNo, I have a different mailing address
Mailing Address

If different from Business Address Entered Above
Mailing Street Address*
Suite / Unit
City*
State*
Zip*

Bank Information (for deposits)

Where would you like us to deposit your funds?
Bank Name*
Name on Bank Account*
Account Number #1 (DDA)*
Bank Routing #1 (ABA)*
Type of Bank Account *
Bank Information (for withdrawals)
Do you want to use the same bank account details for withdrawals?

Yes, use the same account listed aboveNo, I want to enter a different bank account for withdrawals
Bank Name*
Name on Bank Account*
Account Number #2 (DDA)*
Bank Routing #2 (ABA)*
Type of Bank Account *

Documents to Upload (OPTIONAL)
Uploading the following documents is optional at this time and can be collected at a later time.

However uploading the documents now will speed up your application approval time.
Owner's Drivers License

Cancelof
Voided Check or Bank Letter

Cancelof
Bank Statements (last 3 months)

Cancelof
Processing Statements (last 3 months)

If applicable
Cancelof

Signature
BY SIGNING BELOW, MERCHANT AGREES TO ALL OF THE FOLLOWING AND CERTIFIES UNDER THE PENALTIES OF PERJURY THAT THE STATEMENTS BELOW ARE TRUE AND ACCURATE:

1. TAXPAYER I.D. NUMBER- The Tax Payer Identification Number as shown above (TIN) is my correct taxpayer identification number.

2. BACKUP WITHHOLDING- I am not subject to backup withholding, either because I have not been notified that I am subject to withholding as a result of a failure to report all interest or dividends, or the IRS has notified me that I am no longer subject to backup withholding.
Name of Signer*

First NameLast Name
Signature*

Clear
Should be Empty:

Business Information