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"*" indicates required fields

1Your Information

2Business Information

3Business Ownership

4Credit Card Processing

5Business Background

6Marketing & Fulfillment

Your Information

Name of Person Filling Out This Form*

(doesn't have to be the owner)

First Last

Email Address*

Will become your username

Mobile Phone #*

Business Registration

Legal Business Name*

Listed on Tax Return

DBA Name*

Doing Business As

Federal Tax ID #

Numbers only - no dashes or letters.

Business Entity Type*

Business Start Date

Date your business was incorporated (as listed on your Articles of Incorporation.)

Business Address

We can only work with Merchants Incorporated in US, Canada, Mexico, Australia, New Zealand, Switzerland, and the European Union.

Legal Business Address

Street Address City State / Province / Region ZIP / Postal Code Country

DBA Address

Same as Legal Business Address

State of Incorporation

Business Contact Information

Business Contact Email

Location Fax

Website*

Please enter N/A if you don't have one

Time Zone

Business Details

Number of Employees

Please enter a number from 0 to 9999.

Number of Locations

Please enter a number from 0 to 9999.

Billing Descriptor

Preferred Billing Descriptor

0 of 13 max characters

This is how your business will appear on your customers' credit card statements. The first 13 characters (along with your customer service #) will appear on your customers’ credit card statement i.e. “McDonaldsRest8005551234”

Detailed Description of what you're selling:*

Please write brief paragraph with details about what you are selling

Site Survey

Do you own or rent your business location?

What type of building are you located in?

What type of zone is your location in?

Square Footage of Location

Owner Information

Name

First Last

Title

Date of Birth

Mobile Phone Number

You will receive SMS notifications and phone calls regarding your application

SSN

Please enter your Social Security Number

Ownership Percentage

Please enter a number from 0 to 100.

Please enter a number from 0 to 100.

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Do you own or rent?

How many years have you owned the business?

How many months have you owned the business?

Drivers License State

Passport Country

Passport #

My Business has only 1 owner

Yes

Merchant's Banking Information

Information regarding your business bank account. Once approved, your merchant bank will settle the funds collected from your customers from your merchant account into your business bank account.

Bank located in US?

Yes

Is your bank account based in the US?

Name of Bank Contact Person

Enter the name of a bank employee who can be contacted with questions about your bank account.

Bank Contact Phone #

The phone number for the branch or bank employee who helps you with your bank account.

Bank Name

Enter the name of the bank where your funds will be deposited into.

Bank Account Type

Bank Account Number

Enter your bank account number

Routing Number / Transit ABA

Enter your routing number here.

Credit Card Processing

Would you like to accept American Express?

Yes

Current processor(s) or where you’ve already applied

List all credit card processors you're currently using or have applied to already.

Previous Processor(s)

List all credit card processors with whom you've processed payments with before but are not currently processing with.

Do you currently accept credit cards?

Yes

Underwriters will check your bank statements for deposits from credit card processors. If you have deposits from credit card processors you will need to provide 3 months processing history.

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