Pre Application Form
Thanks for choosing Vital Monkey! Please provide all of the required information below, this information is used to help us expedite the application process.
Legal Name of Practice
*
Doing Business As Name (DBA)
If doing business under a different name than legal name.
Federal Tax ID Number
*
Business Start Date
*
-
Month
-
Day
Year
State of Business Incorporation
*
Nature of Medical Practice
*
Briefly describe the nature of your medical practice.
Will you accept credit card payments for anything other than medical services rendered?
*
Yes
No
What is the product or services that you will accept card payments for other than medical services?
Website URL (if applicable)
Addresses & Contact Information
Physical Business Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Do you use a different mailing address?
*
Yes
No
Business Mailing Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Business Phone
*
-
Area Code
Phone Number
Business Fax
-
Area Code
Phone Number
Primary Contact Person
*
First Name
Last Name
Primary Contact - Email Address
*
example@example.com
Primary Contact - Direct Phone Number
*
-
Area Code
Phone Number
Is the name of the authorized signer on account different than the primary contact above?
*
Yes
No
Authorized Signer - Contact Person
*
First Name
Last Name
Authorized Signer - Email Address
*
example@example.com
Authorized Signer - Direct Phone Number
*
-
Area Code
Phone Number
Credit Card Usage, Activity & Estimates
Monthly Card Sales Volume
*
What is the monthly sales volume for credit card based purchases?
Estimated Highest Ticket Amount
*
What is the highest dollar amount that you will transact in a single transaction?
Average Ticket Amount
*
What is the average dollar amount that you will transact in a single transaction?
Banking Details
Provide the banking account details for deposits and refunds below:
Bank Name
*
Routing Number
*
Account Number
*
Do you wish to use a separate bank account for your fees?
*
Yes
No
Bank Name (fees)
*
Routing Number (fees)
*
Account Number (fees)
*
Submit
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