Merchant Pre-Qualification Form
Owner Information
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
SSN
Residential Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Title
*
Ownership %
*
Enter a number only
Business Information
Legal Business Name
*
DBA
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Federal Tax ID Number
*
Date Business Started
-
Month
-
Day
Year
Date
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Corporate Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Ownership Type
*
Sole Proprietor
Partnership
Corporation
LLC
Other
Bank & Financial Info
Bank Name
*
Estimated Monthly Card Volume
*
Routing Number
*
Account Number
*
Average Ticket Price
*
Highest Priced Item
*
Required Attachments
Voided Check
*
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of
Recent Bank Statement
*
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of
Driver’s License
*
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Front & Back - Multiple Files Allowed
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of
Tax Return
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of
Articles of Incorporation / Corporate Docs
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of
Submit for Pre-Qualification
Should be Empty: