Pre Application Form

Pre-Application - New Client
Name:*
E-Mail: (this email will be used for your merchant account)*
example@example.com
Cell Phone*
Date of Birth*

MonthDayYear
Date
Social Security Number*
Home Address*

Address

Street Address Line 2

CityState

Zip Code
Legal Name of Business*
Website URL
Business Legal Address*

Address

Street Address Line 2

CityState

Zip Code
Business Phone Number*
EIN Number, if Sole Proprietor SSN number will work*
Type of business structure*

CorporationLLC/LLPSole ProprietorPartnershipNon-Profit
Business Start Date*
Bank Account Routing Number*
Bank Account Number*
Bank Name*
DBA Name of business if different from legal name
DBA Address if different from legal address

Address

Street Address Line 2

CityState

Zip Code
Type/Description of Business and items sold:*
Average transaction estimate*
High Transaction approval requested amount*
Expected monthly volume*
Additional Information
The provided information will be used for creating your docu-sign merchant application which will be sent to you for your review.

The Payment Doctor himself or a member of his team may reach out to verify any information or for questions.

Thank you for trusting The Payment Doctor and his team for your electronic payments needs!
Signature

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I verify that the information I provided above is true and accurate to the best of my knowledge.

By signing above I'm aware this is not a legally binding agreement and just a Pre-Application for gathering information to have my official application Pre-Filled.
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Pre-Application - New Client