Becoming a blinxPay™ Merchant

1
What’s the name of your business?Tell us the official name of your business as registered
Legal Business Name
2
Do you have a different trade name?Some businesses operate under a different name from their registered name
Doing Business As
3
What do you primarily sell?Select the type of product(s) you sell most often to start personalizing blinxPay to your business
Please Select
Please Select
Food / drink
Retail goods
Grocery / gourmet / alcohol
Beauty / wellness bookings
Healthcare services
Sports / fitness classes
Home / repair services
Medical cannabis
Online gaming
Professional services
Something else
4
What’s your business email?We’ll use this email for all official communications
Business Email
5
What's the primary phone number for your business?Include a contact number we can use for urgent inquiries or support
Primary Phone
6
What type of business are you?Choose the legal structure of your business
Please Select
Please Select
Sole Proprietorship
Limited Liability Company (LLC)
Corporation — S Corp, C Corp, Inc., Private Company or Public Company (Unlisted)
Partnership — General Partnership, Limited Partnership, or Limited Liability Partnership
Charities and Nonprofits — 503(c)(3) or 501(c)(4) organization
Type of Legal Entity
7
What’s your business Employer Identification Number (EIN) or Tax ID?This helps us verify your business for secure transactions
Business EIN / Tax ID
8
What's your registered business address?Please provide the full address on your legal documents
Registered Business Address
9
Does your business have a website?Enter the URL of your business website if available
Business Website
10
How many employees are in your business?
Please Select
Please Select
Just me
1-10 employees
11-50 employees
51-100 employees
More than 100 employees
11
What products/services does your business sell primarily?This will help us categorize charges for your customer purchases. List out what mostly associate to the majority of your charges.
Type of Business
12
To protect your business and prevent fraud, please upload a legal document with your business EIN is shownAcceptable documents: Form SS-4, CP 575, tax returns, business licenses and permits. Please upload the file in pdf, jpg, jpeg, png, doc, or docx format.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
13
On average, what's the number of payments your customers make to you via bank accounts or Zelle each month?
14
What's the number of payments your customers make to you via credit/debit cards each month?
15
On average, how much does your customer pay you per transaction?* This field is required.Enter the amount in USD
Average Amount per Transaction
16
What's the most amount of money your customer has paid/will pay you in one transaction?* This field is required.Enter the amount in USD
Highest Amount per Transaction
17
Approximately, how much does your business transact in total each month?Enter the amount in USD
Total Transaction Amount per Month
18
Do you have chargebacks? If yes, how many on a monthly average?* This field is required.*Chargebacks are credit/debit card disputes. It's when a customer claims they do not recognize or authorize a transaction.
19
What's the average total amount of chargeback you get each month (in USD)?* This field is required.
20
What's your legal name?* This field is required.
First Name of Responsible Party 1
Last Name of Responsible Party 1
21
What's your date of birth?* This field is required.
Birthdate of Responsible Party 1
Month
Day
Year
22
Please provide your legal address* This field is required.Make sure this matches what's on your government-issued ID
Legal Address of Responsible Party 1
23
What's the best email to reach you?* This field is required.
Email of Responsible Party 1
24
What's your primary phone number?* This field is required.
Phone Number of Responsible Party 1
25
If you're referred to blinxPay by someone, please enter their Referral Code here
26
Please provide your full social security number or ITIN* This field is required.
SSN or ITIN of Responsible Party 1
27
To protect your business and prevent fraud, attach a government-issued ID. Acceptable documents: Driver's License, State ID, Passport, Visa. Please upload the file in pdf, jpg, jpeg, or png format.blinxPay uses this for identity verification and tax-reporting. Your information is stored securely in our system and never shared with anyone else.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Attached ID of Responsible Party 1
Cancelof
28
Do you wish to provide information for another person who is responsible for the business?* This field is required.This person should own more than 25% of the business. This will help ensure communications from us always reach at least one person in your business.
YESNO
29
What's their legal name?
First Name of Responsible Party 2
Last Name of Responsible Party 2
30
What's their date of birth?
Birthdate of Responsible Party 2
Month
Day
Year
31
What's their legal address?Make sure this matches what's on their government-issued ID
Legal Address of Responsible Party 2
32
What's the best email to reach them?
Email of Responsible Party 2
33
What's their primary phone number?
Phone Number of Responsible Party 2
34
Please provide their full social security number or ITIN
SSN or ITIN of Responsible Party 2
35
To protect your business and prevent fraud, attach a government-issued ID. Acceptable documents: Driver's License, State ID, Passport, Visa. Please upload the file in pdf, jpg, jpeg, or png format.blinxPay uses this for identity verification and tax-reporting. Your information is stored securely in our system and never shared with anyone else.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Attached ID of Responsible Party 2
Cancelof
36
By signing below, you certify on behalf of the Business that the answers and responses above are true and accurate. Veritec Inc.* and/or its subsidiaries may rely on the information provided herein. Additionally, you authorize blinxPay, a service provided by Veritec Inc., to verify the accuracy of all details submitted. We may conduct identity verification checks directly or through authorized third parties to ensure all details meet our security and compliance standards.* This field is required.*Veritec Inc. is the owner of Veritec Financial Systems Inc., doing business as blinxPay™
Powered by Jotform SignClear
37
Your full name and title* This field is required.
Full Name
Title
38
Signature date* This field is required.
Signature Date
Month
Day
Year
Should be Empty: