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Referral Agent Your Are Working With

CORP/LEGAL ENTITY INFORMATION

Business Name (DBA)

Address

Phone

Time In Business

EIN/Tax ID

Website

BANKING INFO

MUST PROVIDE EITHER A VOIDED CHECK OR BANK LETTER. AN UPLOAD OPTION IS PROVIDED AT THE BOTTOM OF THIS FORM

Bank Name

Routing Number

Account Number

OWNER(S) INFORMATION

First name

Last name

SSN (MUST PROVIDE)

Date of Birth (MUST PROVIDE)

Title

Ownership %

Phone

Address

BUSINESS INFORMATION

Type of Product(s) or Service(s) Sold

% of Sales to Consumers

% of Sales to Businesses

% of Sales eCommerce

% of Sales Mail/Telephone Order

% of Sales Card Present/In-person

Average Ticket Amount

High Ticket Amount

Current Monthly Credit/Debit Volume

If your business is a start-up, what is the anticipated monthly volume?

ADDITIONAL HELPFUL QUESTIONS

Do you use a POS System? If YES please provide the name of your POS System

Do you use physical terminals? If YES please provide the name of the terminals

If you use Shopify please indicate which Shopify plan you are using, Basic, Shopify, Advanced, or Plus

Is it required for your merchant account to integrate into any specific system or software? If YES please provide the name of any and all systems and or softwares

Items that MUST be uploaded below

Three months of most recent processing statements (if existing business with processing history)
Three months of most recent bank statements (if existing business)
Voided Check or Bank Letter with routing and account number listed.
Copy of driver's license for all owners

If Non-Profit please provide proof of 501c3

File upload

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