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Please complete this form with the most up to date information about your business. We will use this information to create the agreement for your new merchant account. Our team will follow up within one (1) business day.
10
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1
Site Information
*
This field is required.
All fields required and information should match signage and advertising for wash. Information will be displayed on receipts and customer statements.
Name
Street Address
City
State
Zip Code
Phone Number
Site
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Site
Name
Row 0, Column 0
Street Address
Row 0, Column 1
City
Row 0, Column 2
State
Row 0, Column 3
Zip Code
Row 0, Column 4
Phone Number
Row 0, Column 5
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Enter
2
Legal Entity Information
*
This field is required.
All fields required.
Name
Street Address
City
State
Zip Code
Phone Number
Legal Entity
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Legal Entity
Name
Row 0, Column 0
Street Address
Row 0, Column 1
City
Row 0, Column 2
State
Row 0, Column 3
Zip Code
Row 0, Column 4
Phone Number
Row 0, Column 5
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3
Business Structure
*
This field is required.
LLC
Corporation
Partnership
Ltd Liability Partnership
Sole Proprietorship
Entity Type
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Entity Type
LLC
Row 0, Column 0
Corporation
Row 0, Column 1
Partnership
Row 0, Column 2
Ltd Liability Partnership
Row 0, Column 3
Sole Proprietorship
Row 0, Column 4
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4
Tax Filing Information
*
This field is required.
All fields required. Please complete this form with the information as it shows on your tax return. If you have not yet filed taxes for this business, use the information provided on your EIN letter.
.
Business Name (as shown on last tax return)
Row 0, Column 0
Date business formed (MM/DD/YY)
Row 1, Column 0
Taxpayer ID
Row 2, Column 0
Business Name (as shown on last tax return)
Date business formed (MM/DD/YY)
Taxpayer ID
.
Row 0, Column 0
.
Row 1, Column 0
.
Row 2, Column 0
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5
Ownership & Officers
*
This field is required.
Each owner with a 25% or greater stake in the business must be shown on this form. If a designated officer is signing the agreement, they must also provide this information. This form is on a secure server and your sensitive data will be encrypted.
Name
Social Security Number
Date of Birth (MM/DD/YY)
Percent Owned
Residential Address
Residential Phone Number
Email Address
Owner 1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
Owner 2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Row 1, Column 6
Owner 3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Row 2, Column 6
Owner 4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Row 3, Column 5
Row 3, Column 6
Officer
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Row 4, Column 5
Row 4, Column 6
Owner 1
Owner 2
Owner 3
Owner 4
Officer
Name
Row 0, Column 0
Social Security Number
Row 0, Column 1
Date of Birth (MM/DD/YY)
Row 0, Column 2
Percent Owned
Row 0, Column 3
Residential Address
Row 0, Column 4
Residential Phone Number
Row 0, Column 5
Email Address
Row 0, Column 6
Name
Row 1, Column 0
Social Security Number
Row 1, Column 1
Date of Birth (MM/DD/YY)
Row 1, Column 2
Percent Owned
Row 1, Column 3
Residential Address
Row 1, Column 4
Residential Phone Number
Row 1, Column 5
Email Address
Row 1, Column 6
Name
Row 2, Column 0
Social Security Number
Row 2, Column 1
Date of Birth (MM/DD/YY)
Row 2, Column 2
Percent Owned
Row 2, Column 3
Residential Address
Row 2, Column 4
Residential Phone Number
Row 2, Column 5
Email Address
Row 2, Column 6
Name
Row 3, Column 0
Social Security Number
Row 3, Column 1
Date of Birth (MM/DD/YY)
Row 3, Column 2
Percent Owned
Row 3, Column 3
Residential Address
Row 3, Column 4
Residential Phone Number
Row 3, Column 5
Email Address
Row 3, Column 6
Name
Row 4, Column 0
Social Security Number
Row 4, Column 1
Date of Birth (MM/DD/YY)
Row 4, Column 2
Percent Owned
Row 4, Column 3
Residential Address
Row 4, Column 4
Residential Phone Number
Row 4, Column 5
Email Address
Row 4, Column 6
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6
Banking Information
*
This field is required.
Bank Name
Routing Number
Account Number
Account Information
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Account Information
Bank Name
Row 0, Column 0
Routing Number
Row 0, Column 1
Account Number
Row 0, Column 2
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7
Type of Card Reader Ordered
*
This field is required.
EMV (Chip)
Magstripe (Swipe Only)
Unsure
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8
Anticipated Launch Date
*
This field is required.
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9
Additional Comments
Please enter any additional notes or comments . (If you have more than 2 pay stations, please let us know how many below)
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10
Email Address
Please enter one (1) email for the DRB In-Bay Solutions Payments Team to use to follow up with you.
example@example.com
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