MIRAI INTAKE FORM

Mirai Intake Form

The Future of Payments
Thank you for selecting Mirai to serve as your credit card processor. Please provide the requested information below and accept the terms of service at the end of the form. We look forward to serving you.
MAIN CONTACT PERSON*

First NameLast Name
MAIN CONTACT TITLE*
MAIN CONTACT NUMBER*
MAIN CONTACT EMAIL*
example@example.com
ARE YOU THE PRIMARY OWNER
OWNERSHIP INFORMATION
PRIMARY OWNER'S NAME*

First NameLast Name
PRIMARY OWNER'S TITLE*
PRIMARY BUSINESS PHONE*
PRIMARY MOBILE PHONE*
PRIMARY BUSINESS OWNER - EMAIL*
example@example.com
PRIMARY OWNER'S RESIDENCE ADDRESS*

Street Address

Street Address Line 2

CityState

Zip Code
ADDITIONAL OWNERS: Are there any additional owners (not including yourself) who own, directly or indirectly, 25% or more of the equity interest of the business?*
OWNERSHIP TYPE*
DBA NAME*
BUSINESS LEGAL NAME*
TAX ID (EIN)*
EIN Format: 12-3456789
BUSINESS START DATE*
MM-YYYY
BUSINESS WEBSITE
BUSINESS PHONE NUMBER
BUSINESS ADDRESS*

Street Address

Street Address Line 2

CityState

Zip Code
IS MAILING ADDRESS THE SAME*
MAILING ADDRESS*

Street Address

Street Address Line 2

CityState

Zip Code
PRIVACY POLICY TERMS AND CONDITIONS
By entering your name and selecting the box below, you agree to the privacy policy terms and conditions.
CONFIRMATION*

Yes, I have read and agree to the terms and conditions
YOUR NAME*
Authorizing Individual
Should be Empty:

Mirai Intake Form