New Client Application

General Information

Client's Business Name*

Client's Corporate / Legal Name*

Business Location

Location Address

Address*

City*

State*

Zip*

Corporate Location

Corporate Address

Address*

City*

State*

Zip*

Contact Information

Location Phone*

Location FAX*

Contact Name*

Contact Phone*

Customer Service Phone*

Contact Email*

Business Structure

Business Type*

Federal Tax ID*

Tax Type*

Prior Security Breach?*

Tax Filing Name*

Business Website Address*

Business Email*

D&B# (Optional)

Multiple Locations?*

If yes, enter # of locations*

Date Business Started*

Length of Current Ownership*

Send Retrieval / Chargeback Requests to:*

State Filing*

NOTE: Failure to provide accurate information may result in a withholding of merchant funding per: IRS regulations.

Owners/Partners/Officers

OWNER/PARTNER/OFFICER 1

Name*

Title*

% of Ownership*

Guarantor*

Address*

City*

State*

Zip*

Phone*

Social Security #*

Date of Birth*

Email*

Add Additional Owners

OWNER/PARTNER/OFFICER 2

Name*

Title*

% of Ownership*

Guarantor*

Address*

City*

State*

Zip*

Phone*

Social Security #*

Date of Birth*

Email*

OWNER/PARTNER/OFFICER 3

Name*

Title*

% of Ownership*

Guarantor*

Address*

City*

State*

Zip*

Phone*

Social Security #*

Date of Birth*

Email*

OWNER/PARTNER/OFFICER 4

Name*

Title*

% of Ownership*

Guarantor*

Address*

City*

State*

Zip*

Phone*

Social Security #*

Date of Birth*

Email*

Bank Account Information

Bank Name*

Bank Phone*

Routing Number*

Account Number*

ACH Method*

Trade Reference (optional)

Trade Ref. Bus. Name

Business Address

City

State

Zip

Contact

Phone

855.468.7876

7900 Glades Rd, Suite 340

General Information

Business Location

Corporate Location

Contact Information

Business Structure

Owners/Partners/Officers

Bank Account Information

Trade Reference (optional)

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