Merchant Automation - PAYBOTX MPA V.T1

APPLICATION FOR MERCHANT CARD PROCESSING
Sales Agent Name*
BUSINESS INFORMATION
Legal Name of Business*
(As filed to the state)
DBA Name
(Storefront Name)
Legal Address*
City, State, Zip*
Phone Number*

Area CodePhone Number
Email Address for Notices*
example@example.com
Customer Service Phone Number*

Area CodePhone Number
Length of Years the Business has been owned*
Website Address *
www.example.com
Is the DBA Address Different from Legal Address?*

YesNo
DBA Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Statements?

Legal AddressDBA AddressElectronic
Chargebacks?

Legal AddressDBA AddressEmail
Products or services sold*
Please provide a detailed response
W-9 INFORMATION

Input information as shown on your income tax return
Taxpayer Identification Number: Must be 9 digits (EIN or SSN)*
EIN for Corporation or LLC / SSN for Sole Proprietorship
Taxpayer Identification Number*

EINSocial Security Number or
Legal Business Name (as shown on your income tax return)*
(Must match Legal Name, confirm be reviewing you EIN Letter)
Type of Ownership*

Sole ProprietorshipLLCPartnershipLtd Liability PartnershipGovernment EntityCorporationNon Profit Corporation
BENEFICIAL OWNER INFORMATION

The owner must have a USA Social Security Number in order to proceed with this application. If the merchant has an ITIN the application will not proceed and an alternative application will need to be filled out.
Full name of owner (as shown on ID)*
Date of Birth*

MonthDayYear
Date
SSN*
Percent Owned (%)*
U.S. Person Non-U.S. Person*

U.S. Person Non-U.S. Person
Residential Address, City, State, Zip*
Phone Number*
Please enter a valid phone number.
Please upload a copy of your ID *

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Title of person opening account *
(Manager, Owner, President)
CARD PROCESSING INFORMATION
Average Credit/Debit Transaction Amount*
Example: $30, $50, $150, etc. (full dollar amount only, no ranges)
Total Credit/Debit Monthly Sales*
Example: $50,000 (full dollar amount only, no ranges)
Please provide a percentage of where the transaction method will take place. If E-commerce is selected, the business must have a website with a functioning shopping cart.
% of transactions Swiped/ In Person*
1/3 Total of these three must equal 100 below
% of transactions key in Manually/ Phone*
2/3 Total of these three must equal 100 below
% of transactions performed Online/Ecommerce*
3/3 Total of these three must equal 100 below
Total Must Equal to 100%
BANKING INFORMATION

All transactions such as sales and chargebacks will be credited or debited, as applicable, to the bank account specified below. Accepted forms of bank account verification are Voided Check, or an official bank letter (No screenshots allowed!)
Bank Name*
Routing Number*
Bank Account Number*
Please upload a copy of a voided check to verify banking information*

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Disclaimers

Please note that the following information may be required by the processing bank. If additional information is requested by the underwriter and the merchant does not provide it, this may result in a delay or potential decline of the application.
- Voided Check or Bank letter signed by a banker must be provided. All other forms are not permitted
- Valid identification: ID or Passport
- Proof of Buisness may be required depeneding on the type of business or if the underwriter has any alerts regaring the legitamacy of the account.
- EIN Letter

-Business License
- ITIN is not accepted under this processor. ITINs are a nine-digit number begining with a “9”
- EBT: if the merchant wants to accept EBT Food a FNS letter must be provided.
- High average tickets may be required to provide invoices, processing statements or bank statements.
- Lease Agreement/ Utility Bill may be required if the Underwriter needs to verify the merchants home address.
- Truepic: May be required if the Underwriter needs to verify the physical business location or inventory. A link will be sent to the phone number and email listed on the application.
- Contractors will need to provide a copy of their Service Agreement or Contract issued to customers.
- If the merchant is not in good standing with the Secretary of state the merchant will need to get back in good standing before the account is approved.
- Hawk alerts must be removed
- Credit Freeze must be lifted or it will delay the approval process
- A hard credit check is ran.
Merchant Signage
Date

MonthDayYear
Date
Signature (please ensure it matches the ID)*

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APPLICATION FOR MERCHANT CARD PROCESSING

BUSINESS INFORMATION

W-9 INFORMATION

BENEFICIAL OWNER INFORMATION

CARD PROCESSING INFORMATION

BANKING INFORMATION

Disclaimers

Merchant Signage