Agent's Name

Please provide your information below.

First Name *

Last Name *

Owner's Address *

Owner's City *

Owner's State *

Owner's Zip *

Mobile Phone Number *

Email *

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MERCHANT INFORMATION

Legal Business Name *

Type of Ownership *

Federal Tax ID# *

Address

Street Address *

City *

State *

Country

Postal code *

Incorporated State *

Business Start Date *

Complete if different from LEGAL NAME

Doing Business As Name

DBA Address

DBA City

DBA State (Abbreviation Only)

DBA Zip Code

OWNERS/OFFICERS/PARTNERS

Social Security Number *

Date of birth *

Bankruptcies Within the Last Five Years? *

Yes

Upload Driver's License *

OWNERS/OFFICERS/PARTNERS

Do you have 100% equity ownership? *

Yes

OWNERS/OFFICERS/PARTNERS

Owner #1 Equity Ownership %

Owner #2 Equity Ownership %

OWNERS/OFFICERS/PARTNERS

Owner #2 Name

Owner #2 Residence Address

Owner #2 City

Owner #2 State

Owner #2 Zip Code

Owner #2 Date of Birth

Owner #2 Social Security Number

Owner #2 Email

Owner #2 Phone Number

General Business Info

Monthly Card Sales

Average Ticket Transaction

High Ticket Transaction

Types of Goods and Services Sold?

Do You Have a Website

Yes

Website

Bank Name

Deposit Routing Number

Deposit Checking Account Number

Voided Check

Upload your 501(c) or 501(c)(6) if you are a non profit

For Non Profit Organization Only