Quick App
Please complete all required fields
Business Info
Business Legal Name
*
Business DBA
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Phone Number
*
E-mail
*
example@example.com
Type of Business
*
Please Select
Corp
LLC
Sole Prop
Partnership
Business
Business Start Date
*
Tax ID / EIN
*
9 Digit Tax ID / EIN (XX - XXXXXXX)
Signor Info
Signor Name
*
First Name
Last Name
Signor Title
(President, V.President, Owner, Member, Secretary/Treasurer)
Signor Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Signor Home / Cell Phone
*
Please enter a valid phone number.
Birthdate
*
-
Month
-
Day
Year
Date
SSN
*
9 Digit SSN (XXX-XX-XXXX)
Business Bank Info
Business Bank Account Number
*
Account Number
Business Bank Routing Number
*
9 Digit Routing Number (XXXXXXXXX)
Submit Voided Check Here
Signature
*
I agree that the information provided is true and subject to penalty by law
Message
(Optional) Special Note to the Tidewater Payment Solutions Staff
Submit
Should be Empty: