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/Tax idenification 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 (Dollar amount based on 1 individual sale average)*
High Transaction approval requested amount (Dollar amount for the largest individual sale purchase)*
Expected monthly volume (total $ amount of monthly credit card charges)*
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

Powered by Jotform SignClear
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.
Should be Empty:

Pre-Application - New Client