Merchant Intake Form

Merchant Intake Form
Business Information
Rep Sales
Business Legal Name
The business name on legal documents ie. "Mister Pants Ltd"
Business "Operating" Name
The name your business uses day to day. Special characters are not allowed
Legal Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Location Address same as Legal Address?
The Location address is the location where the vending machine will be placed and operated
Location Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Shipping Address same as Location Address?
Shipping Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business phone number
Business e-mail address
Website Address
Business Start Date MM/DD/YYYY

MonthDayYear
Date
Ownership Type
Business Registration / EIN / HST #
Describe Products/Services Sold
Equipment Vendor/Supplier
Company supplying vending machine/kiosk/bay meter etc

Financial Information
Monthly Credit Sales Volume
Total Annual Sales (Card, Cash etc)
Average Transaction Size
Average amount customer spends per sale
Highest Transaction Size
Highest amount customer spends per sale
How many Payment Terminals/Card Readers do you need?
How many Payment Terminals/Card Readers do you need?
How many QR Code Payments (no physical card reader) do you need?
No card reader on the vending machine. Customers scan a QR code with their phone and pay via mobile wallet or manual card entry

OWNER / SIGNING OFFICER INFORMATION
Full Name

First NameLast Name
Title
Ownership Percentage
Must be minimum 25%+ in US and 51%+ in Canada. If signing officer, put 0%
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number
Format: (000) 000-0000.
Email
example@example.com
Date of Birth

MonthDayYear
Date
Social Security Number (SSN)
Mandatory for U.S. For Canada, put 000000000
2nd Owner Full Name

First NameLast Name
2nd Owner - Title
2nd Owner - Ownership Percentage
Must be minimum 25%+ in US and 51%+ in Canada. If signing officer, put 0%
2nd Owner Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2nd Owner - Cell Phone Number
Format: (000) 000-0000.
2nd Owner - Email
example@example.com
2nd Owner - Date of Birth

MonthDayYear
Date
2nd Owner - Social Security Number (SSN)
Mandatory for U.S. For Canada, put 000000000

SUPPORTING DOCUMENTS
1. "Voided" Cheque or Direct Deposit Form (DDF)

Provide one of the following: *Physical or Online Void Cheque with Legal or DBA name pre-printed (preferred) *Bank Letter on bank letterhead showing rep’s contact info, signature, & bank stamp. *Direct Deposit Form with Legal or DBA name pre-printed. Must be signed & dated within 90 days.
1 - Upload Files

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2. Proof of Existence: Articles of Incorporation, Business Registration, EIN Document or any Government Doc (choose one)

Document must match the Legal or DBA name and address on the application.
2 - Upload Files

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3. One Government Photo ID: Driver's License, Passport, State/Provincial ID (choose one)

If owner/signing officer is not a citizen of the country, you must always include both a Driver's License and Foreign Passport
Upload Files

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4. Proof of Purchase of Vending Machine(s) from your supplier

Invoice should include your business name and address. This will help speed up approval of your account
Upload Files

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5. Second Owner - Government Photo ID: Driver's License, Passport, State/Provincial ID (choose one)

If owner/signing officer is not a citizen of the country, you must always include both a Driver's License and Foreign Passport
Upload Files - Second Owner

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Business Information