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We respect your privacy and will safeguard your information. All information is securely stored with PCI Compliant systems, using 1024-bit encryption and SSL protection.

Processing Solution Requested *

In Store - Counter Top Credit Card Terminal

Mobile - Mobile Processing App and Swiper

Gateway - Online, Virtual Terminal, Hosting Payment Page, Invoicing

POS - Full POS System for Retail & Restaurant

Quickbooks payments sync requested *

Yes

No

Business Information

Agent Name

Legal Name *

Merchant Legal Business Name

DBA Name *

Merchant DBA Name

Business Address *

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Business Email *

[email protected]

Business Phone Number *

Please enter a valid phone number

Federal Tax ID *

Federal Tax ID (Must be 9 digits)

Prior Bankruptcies *

Yes

No

Date Business Started *

Mailing Address (if different than above) *

Street Address

Street Address Line 2

City

Postal / Zip Code

Business Legal Formation (choose one) *

Sole Proprieter

LLC

Corporation

Partnership

Non-Profit (must have 501c documentation

Business Type *

Retail (General Sales)

Restaurant

Lodging

Service

Internet

Mail Order

Phone Order

Business to Business

Refund/Return Policy *

No Refund

Refund 30 Days or less

Exchange

Principle Information

Name *

First Name

Last Name

Address *

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Date of Birth *

Social Security Number *

Drivers License Number *

Cell Phone Number *

Email *

[email protected]

Percentage of Ownership *

Please type percentage of ownership

Years in Business *

Please type number of years in business

Bank Information

Bank Name *

Name of bank for merchant deposit

Routing Number *

Account Number *

Processing Information

Projected Annual Sales *

Monthly Sales Volume (how much will you process each month) *

High Ticket Request (what is the highest credit card payment we should approve) *

Average Ticket (what is your average sale amount) *

Products/Services Sold *

Notes (please add any special notes here)

Upload Voided Check

Browse Files Drag & Drop Files Here

Upload Copy of Drivers License

Browse Files Drag & Drop Files Here

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