Initial Information
Type of Funds
*
CAD Company with CAD funds
US company with US funds
CAD company with USD funds in a Canadian Bank
Legal Business Name
*
DBA Name
*
EIN
*
HST/GST/BN
*
Ownership Structure
*
Corporation
Non-profit Corporation
Sole-Proprietor
LLC
General Partnership
Limited Partnership
Tax exempt Organization
Sub S Corp
Ownership Structure
*
Corporation
Not for Profit
Sole -Proprietor
Primary Contact
*
First Name
Last Name
Business Phone #
*
Format: (000) 000-0000.
Business Email
*
DBA Address
*
Street Address
Street Address Line 2
City
State / Province
Zip Code / Postal
Is Legal address different than DBA
*
Yes
No
Legal Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Established Date
*
-
Month
-
Day
Year
Date
Owner/Authorized Signer Legal Name
*
First Name
Last Name
Position
*
% Ownership
*
Email
*
Phone Number
*
Format: (000) 000-0000.
Country of Citizenship
*
Are there additional owners with 25% or greater ownership?
*
Yes
No
2nd Owner legal name
First Name
Last Name
% Ownership
Phone Number
Format: (000) 000-0000.
Product/Services Description
*
Delayed Delivery(# of days between payment and shipment)
*
Company Annual Revenue
*
Projected Monthly Credit Card Sales
*
Average Ticket Amount
*
Highest Ticket
*
Environment:
*
Retail (Terminal)
MOTO (Virtual Terminal)
E-Commerce (Internet)
Omni- Commerce (all 3)
Terminal Type Needed:
*
Quantity Needed
*
Are terminals being shipped to DBA address?
Yes
No
Website / Payment Page URL:
*
Card Split:
Keyed:
*
Merchant manually keying in card #
Swiped:
*
Tapped/inserted/swiped on a physical terminal
Internet:
*
ecommerce (cardholder inputs card #)
Please upload required documents here:
*
Browse Files
Cancel
of
Additional Info:
2nd Owner Additional Info:
Referred by:
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