"*" indicates required fields Step 1 of 6 - Company Information 16% Company InformationMERCHANT DBA NAME* Number of locationsLocation* Has A Physical Location Only Digital (such as a website) Both Physical and Digital Upload a photo of the building's exterior that includes signageMax. file size: 10 MB.Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Contact Name* Primary Contact Phone*Email Address* Website Address* Legal InformationLegal or Corporate Name:* Legal/Corp Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code EIN or Your Country's Tax ID Number* EIN Number SS-4 Form Drop files here or Select files Accepted file types: jpg, gif, png, pdf, docx, doc, jpeg, Max. file size: 20 MB, Max. files: 10. It's recommended to have a copy of this form as this will speed up the application process (1) Owner / Officers/ Authorized Signor(1) Owner / Officor* Owner Officer None Name* Title* SSN or Equivalent DOB* DD slash MM slash YYYY Home Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact Phone*Contact Email* % of Ownership*(2) Owner / Officers/ Authorized Signor(2) Owner / Officor* Owner Officer None Name Title SSN or Equivalent DOB DD slash MM slash YYYY Home Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact PhoneContact Email % of Ownership (3) Owner / Officers/ Authorized Signor(2) Owner / Officor* Owner Officer None Name Title SSN or Equivalent DOB DD slash MM slash YYYY Home Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact PhoneContact Email % of Ownership Merchant DetailType of Business* Public Private Type of Ownership:* Sole Proprietorship Partnership Corporation L.L.C Non-Profit Government/Municipality Upload Articles of Incorporation*Max. file size: 10 MB.Does your business sell products or merchandise?* Yes No Upload list of products and a photo of products sold* Drop files here or Select files Max. file size: 10 MB. Business Name* Date Business Started* MM slash DD slash YYYY Date Acquired by Current Owner* MM slash DD slash YYYY What percentage of sales are Chargebacks?*Do you currently accept Credit Cards* Yes No Current Processor* What percentage of sales are returned?Does your business sell merchandise/physical products?* Yes No Website address:* What Products/Service do you provide:* How soon is Customers card charged?* Do you obtain a signature for your product?* Yes No Return Policy*Business License(s)Please include all licenses your business currently possesses.Upload Current Business License(s) Drop files here or Select files Accepted file types: jpg, gif, png, pdf, docx, doc, jpeg, Max. file size: 20 MB, Max. files: 10. Sales InformationMonthly Volume Visa/Mastercard/Discover* Monthly Volume AMEX* Average Ticket* Max Ticket* Sales Method* Swiped Imprinted MOTO Internet Select AllCurrent Online Gateway* NMI Authorize.net Other N/A Other Gateway Current Terminal or POS system* Clover Ingenico Verifone PAX DejaVoo Other system N/A Other System NotesSubmitted By (Agent) (Please write agent name if applicable) Documents UploadVoided Check* Drop files here or Select files Accepted file types: jpg, gif, png, pdf, docx, doc, jpeg, Max. file size: 5 MB, Max. files: 5. Drivers License Front & Back* Drop files here or Select files Accepted file types: jpg, gif, png, pdf, docx, doc, jpeg, Max. file size: 20 MB, Max. files: 10. Servicing Over 5000+ Merchants
