Sign-Up Form
NOTICE
Before you begin, please ensure you have the necessary documents and information ready. You will need your location's information, a copy of a voided check/bank letter, as well as your sales breakdown (Gross Annual Sales, Average Sale, etc.). Having these prepared in advance will help ensure a smooth and efficient submission process.
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Primary Contact
Contact Name
*
First Name
Last Name
Title
*
Contact Email
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
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Business Information
Business DBA (Doing Business As) Name
*
Business Legal Name
*
Your Business Address (No P.O. Boxes)
*
Street Address
Street Address Line 2
City
State
Zip Code
Your Business Phone Number
*
Please enter a valid phone number.
Your Business Email
*
example@example.com
Your Business Website
*
Your Business Start Date
*
/
Month
/
Day
Year
Date
Products/Services Sold
*
Additional Business Information
Your Business's Billing Address (No P.O. Boxes)
*
Street Address
Street Address Line 2
City
State
Zip Code
Your Business' Entity Type
*
Limited Liability Company/LLC
Private Corporation - Chapter S/C
Individual/Sole Proprietorship
Tax Exempt Organization (501c)
Partnership
State of Formation
*
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Name (as it appears on your income tax return)
*
For your business, not personal tax returns
Federal Tax ID # (as it appears in your income tax return)
*
Type of Business
*
Please Select
Retail
Restaurant
Service-Based
Ecommerce
Healthcare
Beauty & Personal Care
Fitness & Wellness
Hospitality
Automotive
Nonprofit
Education
Professional Services
Grocery & Convenience
Event & Entertainment
Construction & Contracting
Home Services
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Ownership Information
Each individual, if any, who owns, directly or indirectly, 25 percent or more of the equity interests of the legal entity customer (e.g., each natural person that owns 25 percent or more of the shares of a corporation). If more than one applicable owners, please contact info@emeraldpay.com for further instructions after submitting with the primary owner/signer.
First Owner's (Signer's) Name
*
First Name
Last Name
First Owner's (Signer's) Title
*
First Owner's (Signer's) Ownership%
*
First Owner's (Signer's) Date of Birth
*
-
Month
-
Day
Year
Date
First Owner's (Signer's) Social Security Number
*
First Owner's (Signer's) Phone Number
Please enter a valid phone number.
First Owner's (Signer's) Home Address (No P.O. Boxes)
*
Street Address
Street Address Line 2
City
State
Zip Code
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Banking/Financial Information
Banking Information
Bank Name
*
Routing Number
*
Account Number
*
Financial Information
Estimated values are accepted, exact amounts are not required (i.e. $1,556,976.54 in Gross Yearly Sales Volume can be reported as $1,500,000)
Gross Yearly Sales Volume (Cash + Credit + Debit + Check)
*
Must Be equal to or above 100,000
Yearly Visa/Mastercard Volume
*
Must Be Greater than 10,000
Yearly Discover Volume
*
Must Be Greater than 10,000
Yearly American Express Volume
*
Must Be Greater than 10,000
Average Ticket Amount
*
Average Sale Amount
Highest Ticket Amount
*
Highest Expected Sale (Used to set security measures around your account.)
How Do You Mostly Take Payments?
Please Select
In-Person/In-Store
Online/E-Commerce
Over the Phone
Invoices
With A Mobile Reader/Handheld Terminal
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Equipment
All prices listed do not include applicable taxes and shipping fees. With the purchase of a Clover device, you'll gain immediate access to the Clover Dashboard, Virtual Terminal, and Clover Go App for an additional $5.00/month.
My Products
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Clover Compact
Best Cost Effective Device
$
300.00
Quantity
1
2
3
4
5
6
7
8
9
10
Clover Flex
$
713.10
Quantity
1
2
3
4
5
6
7
8
9
10
Clover Mini
$
1,041.35
Quantity
1
2
3
4
5
6
7
8
9
10
Clover Mini With Cash Drawer
$
1,141.35
Quantity
1
2
3
4
5
6
7
8
9
10
Clover Go
Best Option for Services/Contracctors
$
150.00
Quantity
1
2
3
4
5
6
7
8
9
10
Kitchen Printer
$
516.00
Quantity
1
2
3
4
5
6
7
8
9
10
Clover Station Duo with Cash Drawer
Best Option for Retail
$
2,010.10
Quantity
1
2
3
4
5
6
7
8
9
10
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Additional Documents & Signatures
Please review the agreement PDF before submitting. Partially completed or unsubmitted forms will not be recorded. After submission, you can download a copy of the agreement, and a copy will also be emailed to you.
Signature
*
Initials
*
Today's Date
*
-
Month
-
Day
Year
Date
Additional Documentation
Voided Check or Bank Letter required. Starter checks will not be accepted. A bank letter must have a bank letterhead, the company's name, routing number, bank account number, and signature from a bank representative.
Voided Check or Bank Letter
*
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