Tidewater Quick App Form

Quick App

Please complete all required fields
Business Info
Business Legal Name*
Business DBA*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone Number*
E-mail*
example@example.com
Type of Business*
Business
Business Start Date*
Tax ID / EIN*
9 Digit Tax ID / EIN (XX - XXXXXXX)
Business Bank Name
Bank Routing Number
xxxxxxxxx (9 digit number)
Bank Account Number
Business Signor Info
Name*

First NameLast Name
Title
(President, V.President, Owner, Member, Secretary/Treasurer)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home / Cell Phone*
Please enter a valid phone number.
Social Security Number*
123-45-6789
Date of Birth *

MonthDayYear
Date
Message:
(Optional) Special Note to the Tidewater Payment Solutions Staff
Should be Empty: