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Application
Type of Corporation
LLC
Individual
Partnership
Corporation (S or C)
Legal Name of Business
Street Address
City
State
Zip Code
DBA Name
DBA Address (if different than above)
Phone Number
Federal Tax ID
Month & Year Business Began
Web Address
Business Email
Support Email Address
First Name
Last Name
Title
Email
Date of Birth
SSN
Drivers License #
State Issued
Drivers License Issue & Expire Dates
Street Address
City
State
Zip Code
Cell Phone Number
% of Ownership (Need Owner info on all owners over 25%)
Monthly Volume
Average Ticket
Occasional High Ticket
Card Present & Swiped Percentage
Mail Order / Phone Order Percentage
Internet Percentage
Detailed Explanation of Merchandise/Product / Service Sold
Terminal / POS needed
Number of Terminals needed
Detailed Explanation of Type of Merchandise, Products, or Services Sold
VOIDED CHECK (Text Picture ok)
PREVIOUS PROCESSING STATEMENTS IF CURRENTLY PROCESSING
DRIVERS LICENSE – Text Picture ok
Pictures of Terminals, hardware, POS, printers, cash drawers etc…Including serial numbers
Terminal
IP
Wi/Fi / Password
Dial
Retail / Rest
Zoning
Commercial
Industrial
Residential
Building Type
Office
Separate Building
Shopping Center
Residential
Building/Office Sq/Ft
Own / Lease
Any Additional Information
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