Electronic Application Information
All Information Is Encrypted For Your Safety And Security
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Business Information
Legal Business Name
Legal Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
DBA (Doing Business As) Name
DBA Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
DBA Phone
Please enter a valid phone number.
Format: (000) 000-0000.
DBA email
example@example.com
Date Business Opened/Established
-
Month
-
Day
Year
Date
Type Of Ownership (LLC, Corp, Sole Proprietorship etc.)
EIN Number (XX-XXXXXXX)
SSN if Sole Proprietorship with no EIN
EIN Number (XX-XXXXXXX)
*
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1st Owner Information
(full name, ownership %, SSN, birthdate, home address and cellular number for anyone with more than 25% ownership.
Owner 1 Full Name
First Name
Last Name
Owner 1 Ownership Percentage
Example 50%
Owner 1 Social Security Number
xxx-xx-xxxx
Owner 1 Birthdate
-
Month
-
Day
Year
Date
Owner 1 Full Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Owner 1 Mobile Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Owner 1 Email Address
example@example.com
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2nd Owner Information (Skip If Not Applicable)
(full name, ownership %, SSN, birthdate, home address and cellular number for anyone with more than 25% ownership.
Owner 2 Full Name
First Name
Last Name
Owner 2 Ownership Percentage
Example 50%
Owner 2 Social Security Number
xxx-xx-xxxx
Owner 2 Birthdate
-
Month
-
Day
Year
Date
Owner 2 Full Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Owner 2 Mobile Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Owner 2 Email Address
example@example.com
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3rd Owner Information (Skip If Not Applicable)
(full name, ownership %, SSN, birthdate, home address and cellular number for anyone with more than 25% ownership.
Owner 3 Full Name
First Name
Last Name
Owner 3 Ownership Percentage
Example 50%
Owner 3 Social Security Number
xxx-xx-xxxx
Owner 3 Birthdate
-
Month
-
Day
Year
Date
Owner 3 Full Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Owner 3 Mobile Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Owner 3 Email Address
example@example.com
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4th Owner Information (Skip If Not Applicable)
(full name, ownership %, SSN, birthdate, home address and cellular number for anyone with more than 25% ownership.
Owner 4 Full Name
First Name
Last Name
Owner 4 Ownership Percentage
Example 50%
Owner 4 Social Security Number
xxx-xx-xxxx
Owner 4 Birthdate
-
Month
-
Day
Year
Date
Owner 4 Full Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Owner 4 Mobile Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Owner 4 Email Address
example@example.com
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Authorized Signer (Skip If Not Applicable)
Only For Persons OTHER Than Owners That Are To Be Granted Signer/Account Responsibility
Authorized Signer Full Name
First Name
Last Name
Authorized Signer Social Security Number
xxx-xx-xxxx
Authorized Signer Birthdate
-
Month
-
Day
Year
Date
Authorized Signer Full Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Authorized Signer Mobile Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Authorized Signer Email Address
example@example.com
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Processing Program
Please Select
Standard Processing
Cash Discount Assist (Eliminate 50% of Processing Fees)
Cash Discount (Eliminate 100% of Processing Fees)
Do you need or want a virtual terminal (adds $12.50 per month for standard accounts and $17.50 per month for Cash Discount Offset accounts) Includes: Virtual Terminal, Invoicing, Card On File, Recurring Payments and Payment Links.
Please Select
Yes
No
How many stations require card readers?
Please Select
No stations
1
2
3
4
5
6
7
8
9
10
Do you need another form of payment terminal not listed above such as a Countertop/Stand Alone LAN/WiFi or Cellular Credit Card Terminal? If so please describe below all aspects of how you will take payments from your customers and the device type you need.
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Upload Your Documents
Voided Check or Bank Letter
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Starter Checks Are Not Allowed - Bank Letter In Leu Of Voided Check (must be on bank letterhead and state the business name, bank account number and routing number and indicate in good standing and be signed by a banker with contact information).
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Government Issued ID For Owners 1-4 (Drivers License, State ID, Passport etc.)
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Upload IDs For Each Owner
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Processing Statements
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3 Most Recent Processing Statements (if transferring your account from another processor)
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Supporting Documents
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IRS Form SS4 (Required brand new businesses - Recommended for established businesses if readily available)
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Submit
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