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B9D29DC9-6512-4822-974A-43910B226BC1
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Merchant Information
2
Company Structure
3
Funding Information
4
Document Upload
5
Review and Submit
Merchant Information
Complete all required information on this application to get started on your merchant services account or contact your Partner provider for any questions.
Business Profile
Tell us about your business
DBA Name
*
Describe the Business Products or Services offered:
*
Business Type
*
(Select)
Retail
E-Commerce
Mail Order/Telephone Order
Restaurant
Website Url?
*
DBA CONTACT First Name
*
DBA CONTACT Last Name
*
DBA CONTACT Email Address
*
DBA Phone #
*
?
This # is what is used for receipt reporting and may be customer facing.
Alternate DBA Phone #
Business Location Time Zone
*
(Select)
PT - Pacific
MT - Mountain
CT - Central
ET - Eastern
Best Time to Contact
*
(Select)
8am - 10am
10am - 12am
12pm - 2pm
2pm - 4pm
4pm - 6pm
DBA Business Address
*
?
This would be the Physical or DBA Location information.
Suite/Apt
DBA City
*
DBA State
*
(Select)
AL - Alabama
AK - Alaska
AZ - Arizona
AR - Arkansas
CA - California
CO - Colorado
CT - Connecticut
DE - Delaware
DC - District of Columbia
FL - Florida
GA - Georgia
HI - Hawaii
ID - Idaho
IL - Illinois
IN - Indiana
IA - Iowa
KS - Kansas
KY - Kentucky
LA - Louisiana
ME - Maine
MD - Maryland
MA - Massachusetts
MI - Michigan
MN - Minnesota
MS - Mississippi
MO - Missouri
MT - Montana
NE - Nebraska
NV - Nevada
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NY - New York
NC - North Carolina
ND - North Dakota
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VT - Vermont
VA - Virginia
WA - Washington
WV - West Virginia
WI - Wisconsin
WY - Wyoming
DBA Zip
*
Transaction Expectations
Anticipated Card Acceptance Information
Monthly Volume?
*
?
Average of combined monthly Visa, Mastercard and Discover Volume. If you are new to processing, provide your best estimate.
$
Highest Transaction?
*
?
The highest transaction you would ever run. If you are new to processing, just provide your best estimate.
$
Average Transaction Size?
*
?
The amount of your average transaction. If you are new to processing, just provide your best estimate.
$
PLEASE NOTE f/ AVG TICKET:
Average ticket over $1,000 requires document upload of last 3 months of bank statements and/or merchant processing statements
Swiped %
*
?
What is the % of transactions Swiped at the Business? Total between all methods must = 100%
Key Entered%
*
?
What is the % of transactions keyed at the physical location of the business? Total between all methods must = 100%
MOTO %
*
?
What is the % of Mail or Telephone Entered transactions for the business? Total between all methods must = 100%
eCOMMERCE %
*
?
What is the % of eCOMM Entered transactions for the business? Total between all methods must = 100%
Business to Business %
*
?
What is the % of Business you do with other businesses vs consumers?
Business to Consumer %
*
?
What is the % of Business you do with consumers?
PLEASE NOTE f/ CARD ENTRY METHOD USING LESS THAN 70% SWIPED OR KEYED CARD PRESENT
The following MOTO Questionnaire questions are required and will likely cause delays in Underwriting if not completed in full.
MOTO Q - Method of Marketing
(Select)
Newspaper / Magazine
TV / Radio
Internet
Direct Mail / Brochure / Catalog
Outbound Telemarketing
Other
MOTO Q - Order Processed By
(Select)
Merchant
Fulfillment Center
Other
MOTO Q - Card Transaction Entered By
(Select)
Merchant
Fulfillment Center
Consumer
Other
Company Structure
Complete all required information on this application to get started on your merchant services account.
Legal Information
Tell us how your business was formed
Legal Business Name
*
Business Contact Phone #
*
?
Who/What # do we contact for Payments Processing business issues or notices?
Business Email Address
*
?
Business Email Address for the Legal Entity
Legal Entity Type
*
(Select)
Non-Profit
LLC
Corporation
Government
Sole Proprietor
Partnership
Publicly Traded
Federal Tax Identification Number (TIN)
*
LLC State
*
?
The state in which the business was legally formed?
(Select)
AL - Alabama
AK - Alaska
AZ - Arizona
AR - Arkansas
CA - California
CO - Colorado
CT - Connecticut
DE - Delaware
DC - District of Columbia
FL - Florida
GA - Georgia
HI - Hawaii
ID - Idaho
IL - Illinois
IN - Indiana
IA - Iowa
KS - Kansas
KY - Kentucky
LA - Louisiana
ME - Maine
MD - Maryland
MA - Massachusetts
MI - Michigan
MN - Minnesota
MS - Mississippi
MO - Missouri
MT - Montana
NE - Nebraska
NV - Nevada
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NY - New York
NC - North Carolina
ND - North Dakota
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VT - Vermont
VA - Virginia
WA - Washington
WV - West Virginia
WI - Wisconsin
WY - Wyoming
Business Start Date
*
?
"Business Formation Date" - The date the business was formed with the relevant Secretary of State // the date of an organization's incorporation, its registration with the local government or government agency, or the adoption of its founding documents. "Business Formation Date"
Month
January
February
March
April
May
June
July
August
September
October
November
December
Tax Exempt
*
(Select)
No
Yes
PLEASE NOTE if YES to Tax Exempt
** If applying under a Tax Exempt status, an upload of required 501(c)(3) or Tax Exempt documents is required**
Legal Business Address
*
Suite/Apt
Legal Business City
*
Legal Business State
*
(Select)
AL - Alabama
AK - Alaska
AZ - Arizona
AR - Arkansas
CA - California
CO - Colorado
CT - Connecticut
DE - Delaware
DC - District of Columbia
FL - Florida
GA - Georgia
HI - Hawaii
ID - Idaho
IL - Illinois
IN - Indiana
IA - Iowa
KS - Kansas
KY - Kentucky
LA - Louisiana
ME - Maine
MD - Maryland
MA - Massachusetts
MI - Michigan
MN - Minnesota
MS - Mississippi
MO - Missouri
MT - Montana
NE - Nebraska
NV - Nevada
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NY - New York
NC - North Carolina
ND - North Dakota
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VT - Vermont
VA - Virginia
WA - Washington
WV - West Virginia
WI - Wisconsin
WY - Wyoming
Legal Business Zip
*
Country
Officer Information
Individual responsible for direction or management of business operations and authorized signer for the business.
Officer Information 1
First Name
*
Last Name
*
Phone
*
Email
*
Title
*
Own part of the company?
*
(Select)
Yes
No
Has a controlling position?
*
?
Does this individual have authority to manage or direct the companies day to day operations regardless of ownership
(Select)
Yes
No
Ownership %
*
SSN
*
?
Why do I need to provide this?
Federal regulation requires financial institutions to obtain, verify, and record information about individuals who own or control a legal entity (i.e., the beneficial owners). Legal entities can be abused to disguise involvement in terrorist financing, money laundering, tax evasion, corruption, fraud, and other financial crimes. Requiring the disclosure of key individuals who own or control a legal entity (i.e., the beneficial owners) helps law enforcement investigate and prosecute these crimes.
Your Federal Tax ID cannot be used in this field.
Date of Birth
*
?
Why do I need to provide this?
Federal regulation requires financial institutions to obtain, verify, and record information about individuals who own or control a legal entity (i.e., the beneficial owners). Legal entities can be abused to disguise involvement in terrorist financing, money laundering, tax evasion, corruption, fraud, and other financial crimes. Requiring the disclosure of key individuals who own or control a legal entity (i.e., the beneficial owners) helps law enforcement investigate and prosecute these crimes.
Your business registration date cannot be used in this field.
Month
January
February
March
April
May
June
July
August
September
October
November
December
Please double check your social security number (SSN). If your SSN is incorrect, you may need to provide a scanned copy of your social security card to validate its accuracy.
Address
*
Suite/Apt
City
*
State
*
(Select)
AL - Alabama
AK - Alaska
AZ - Arizona
AR - Arkansas
CA - California
CO - Colorado
CT - Connecticut
DE - Delaware
DC - District of Columbia
FL - Florida
GA - Georgia
HI - Hawaii
ID - Idaho
IL - Illinois
IN - Indiana
IA - Iowa
KS - Kansas
KY - Kentucky
LA - Louisiana
ME - Maine
MD - Maryland
MA - Massachusetts
MI - Michigan
MN - Minnesota
MS - Mississippi
MO - Missouri
MT - Montana
NE - Nebraska
NV - Nevada
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NY - New York
NC - North Carolina
ND - North Dakota
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VT - Vermont
VA - Virginia
WA - Washington
WV - West Virginia
WI - Wisconsin
WY - Wyoming
Zip
*
Beneficial Owner Agreement
Certification of Beneficial Owner(s)
*
To help the government fight financial crime, Federal regulation requires certain financial institutions to obtain, verify, and record information about the beneficial owners of legal entity customers. Legal entities can be abused to disguise involvement in terrorist financing, money laundering, tax evasion, corruption, fraud, and other financial crimes. Requiring the disclosure of key individuals who own or control a legal entity (i.e., the beneficial owners) helps law enforcement investigate and prosecute these crimes. By signing below, I attest that I have accurately provided the name, address, date of birth and Social Security Number (SSN) for the following individuals (i.e. the beneficial owners): (i) Each individual, if any, who owns directly or indirectly, 25 percent or more of the equity interests of the legal entity customer (e.g., each natural person that owns 25 percent or more of the shares of a corporation); and (ii) An individual with significant responsibility for managing the legal entity customer (e.g., a Chief Executive Officer, Chief Financial Officer, Chief Operating Officer, Managing Member, General Partner, President, Vice President, or Treasurer). The number of individuals that satisfy this definition of “beneficial owner” may vary. Under section (i), depending on the factual circumstances, up to four individuals (but as few as zero) may need to be identified. Regardless of the number of individuals identified under section (i), you must provide the identifying information of one individual under section (ii). It is possible that in some circumstances the same individual might be identified under both sections (e.g., the President of Acme, Inc. who also holds a 30% equity interest). Thus, a completed form will contain the identifying information of at least one individual (under section (ii)), and up to five individuals (i.e., one individual under section (ii) and four 25 percent equity holders under section (i)). I, the undersigned, certify that all of the information furnished above with regard to information for each individual, if any, who directly or indirectly, through any contract, arrangement, understanding, relationship or otherwise, owns 25 percent or more of the equity interests of the legal entity listed above is complete and accurate.
By checking this box, you acknowledge that you have read and agree to the Certification of Beneficial Ownership
Funding Information
Complete all required information on this application to get started on your merchant services account.
Bank Checking Information
Please provide the bank account information for debit and credit card transaction funding.
Bank Name
*
Name on Account
*
Routing Number
*
Account Number
*
PLEASE DOUBLE CHECK YOUR BANK ACCOUNT INFO. If your information is incorrect, you may need to provide a signed bank letter or voided check to validate its accuracy.
Document Upload
*Required Docs - Partner Completed Pricing Doc Suggested documents to upload for most efficient Underwriting (i.e.; Voided Check or Bank Letter, TAX Exempt documents if applicable, 3 months of most recent processing or banks statements, etc.)
Document Upload
** Required Docs - Partner Completed Pricing Doc
--Suggested documents to upload for most efficient Underwriting (i.e.; Voided Check or Bank Letter, TAX Exempt documents if applicable, 3 months of most recent processing or banks statements, etc.)
Click "Choose Files" to browse for files on your computer or mobile device. Up to 12 files can be uploaded.
Choose file
0 Files
Review and Submit
Please review your applications and click submit.
Business Profile
DBA Name
What does this business do?
Website Url
First Name
Last Name
Email Address
Phone
Alternate Phone
Time Zone
Best Time to Contact
Address
Suite/Apt
City
State
Zip
Country
Questionnaire
How many locations?
Average Monthly Volume
Average transaction
Highest transaction
Legal Information
Legal Name
Legal Entity Type
Federal Tax Id
Business Start Date
Phone
Email
Address
Suite/Apt
City
State
Zip
Country
Officer Information
First Name
Last Name
Phone
Email
Title
Date of Birth
Social Security Number
Own part of the company?
Has a controlling position?
Address
Suite/Apt
City
State
Zip
Country
Bank Information
Bank Name
Name on Account
Routing Number
Account Number
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