QleenPay App 5.42

Business Information

Our application is simple and only takes a few minutes to complete.
DBA
Legal Name of Business
Federal Tax ID
Type of Ownership
DBA Email
example@example.com
DBA Phone
Format: (000) 000-0000.
Business Website

Business Information (cont.)
Business Address
Business Street Address
Suite / Unit
City
State
Zip
Years of Operation
Number of Locations
Business Type
Select Your Industry
Description of Products/Services Sold

Is your mailing address the same as your business address you entered above?
Mailing Address

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

Owners / Officers
First Name
Last Name
Title
Percentage of Ownership %
Owner's Street Address
Suite / Unit
City
State
Zip

Owner Information (cont.)
Social Security Number
Date of Birth

MonthDayYear
Email
Mobile Phone
Format: (000) 000-0000.
Driver License Number
Driver License State

Are there any other owners that own 25% or more of the company?
Owner / Officer #2
First Name
Last Name
Title
Percentage of Ownership %
Owner's Street Address
Suite / Unit
City
State
Zip
Owner Information #2 (cont.)
Social Security Number
Date of Birth

MonthDayYear
Email
Mobile Phone
Format: (000) 000-0000.
Driver License Number
Driver License State

Card Processing Information (cont.)
Avg. transaction amount
Largest transaction amount
Est. monthly processing volume
Highest monthly processing volume

Card Processing Information (cont.)
Do you require customers to pay deposits?
What percentage of the deposit is required?
Does your billing strategy include free trial billing?
What is your return, cancellation, or refund policy?

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?
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
Should be Empty: