New Company Application Merchant Application 1. COMPANY INFORMATION DBA Name * Corporation Name * Contact Name * DBA Address Type * Residential Business Shopping Center DBA Street Address * (No PO Box) City * State * Zip * Country of Primary Business Operations * Entity Type LLC, Private or Public Corporation, Partnership, etc... Business Country of Formation * Length of Current Ownership * Years and Months Email Address * DBA Phone * EIN * Additional Information Enter any additional information that will help underwriting understand your business financial history. 2. PRINCIPAL INFORMATION Is the business owned by a person(s) or a corporation? * Owned by a person or persons Owned by a corporation or trust % of Ownership * Beneficial Owner and signer of the merchant agreement Title * How many owners with 25% or more ownership? * One Owner Two Owners Three Owners Four Owners Is this owner the responsible party? * Yes No Authorized signer: Yes or No Corporation or Trust Name * First Name * Middle Name Last Name * Address Type * Residential Business Military Street Address * (No PO Box) City * State * Zip Code * Have you lived at this address for longer than 2 years? * Yes No Previous Home Address Street, City, State, and Zip (No PO Box) DOB * US Person * Yes No Phone * Are you comfortable sharing your SSN on our Secured Website? * Yes, since it is secured with an SSL No, I prefer a phone call to give it verbally Social Security Number * The phone number we should call? * E.g. 561-123-0983, the afternoon is best SECOND PRINCIPAL INFORMATION Beneficial Owner: Percentage of Ownership * How many owners with 25% or more ownership? One Owner Two Owners Three Owners Four Owners Is this owner the responsible party? * Yes No Authorized signer: Yes or No First Name * Middle Name Last Name * Address Type * Residential Business Military Street Address * (No PO Box) Has this owner lived at this address for longer than 2 years? * Yes No Previous Home Address Street, City, State, and Zip (No PO Box) DOB * US Person * Yes No Phone * Are you comfortable sharing your SSN on our Secured Website? * Yes since it is secured with an SSL No, I prefer a phone call to give it verbally Social Security Number * The phone number we should call you? * E.g. 561-123-0983, the afternoon is best THIRD PRINCIPAL INFORMATION Beneficial Owner: Percentage of Ownership * How many owners with 25% or more ownership? One Owner Two Owners Three Owners Four Owners Is this owner the responsible party? * Yes No Authorized signer: Yes or No First Name * Middle Name Last Name * Address Type * Residential Business Military Street Address * (No PO Box) City * State * Zip Code * Has this owner lived at this address for longer than 2 years? * Yes No Previous Home Address Street, City, State, and Zip (No PO Box) DOB * US Person * Yes No Phone * Are you comfortable sharing your SSN on our Secured Website? * Yes since it is secured with an SSL No, I prefer a phone call to give it verbally Social Security Number * The phone number we should call? * FORTH PRINCIPAL INFORMATION Beneficial Owner: Percentage of Ownership * How many owners with 25% or more ownership? One Owner Two Owners Three Owners Four Owners Is this owner the responsible party? * Yes No Authorized signer: Yes or No First Name * Middle Name Last Name * Address Type * Residential Business Military Street Address * (No PO Box) City * State * Zip Code * Has this owner lived at this address for longer than 2 years? * Yes No Previous Home Address Street, City, State, and Zip (No PO Box) DOB * US Person * Yes No Phone * Are you comfortable sharing your SSN on our Secured Website? * Yes since it is secured with an SSL No, I prefer a phone call to give it verbally Social Security Number * The phone number we should call? * 3. OTHER COMPANY INFORMATION Annual Revenue * Average Sale Amount * The average of each sale or transaction High Sale Amount * Amount of a sale that is the highest of the year Number of High Sales Annually * The number of times the previous question happens Total Monthly Visa/MC/AMEX/DISC/UNIONPAY * Monthly Percent of In-Person and Internet * E.g. 60% In-person and 40% Internet or Phone Equipment Needed? * Terminal Internet/Gateway Moto/Phone Sales VAR (For Current Terminal/System) OtherOther Type of Industry * Retail Restaurant Lodging Internet MOTO Website URL * Internet Contact Email * Customer Service Phone * Previous Processor's Name When does the customer receive the product or service? * If not same day, ____# of days (Include Shipping Time Frame) Description of Product/Service Offered * If your business is seasonal, which months are you closed? E.g. February, April, and October Deposit Bank Name * ABA/Routing # * DBA Account # * If you are human, leave this field blank. Submit Δ
