Nonprofit Organizations Not-for-Profit Merchant Application 1. COMPANY INFORMATION Organization or DBA Name * Nonprofit 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 Estimated Annual Contributions/Donations * Average Amount of each Donation * Highest one-time Donation Expected * How often do you receive these highest donation amounts? * Amount of donations expected to be paid with a Credit/Debit Card? * Monthly Percent of Donations received In-Person and Internet * E.g. 60% In-person and 40% Internet or Phone Website URL * Internet Contact Email * Customer Service Phone * Deposit Bank Name * This is your bank where donations will be deposited to. ABA/Routing # * DBA Account # * This is your bank account number where donations will be deposited into. If you are human, leave this field blank. Submit Δ
