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Application

Business Name (DBA = "Doing Business As" Name) *

Business Location Address *

Business Mailing Address

Business Phone *

Business Email *

# of Years in Business *

Type of Business *

Click drop down arrow to choose Type of Business

Corporate / Legal Name (i.e. Inc. , LLC, Partnership, etc.) *

Corporate Mailing Address *

Corporate Phone *

Industry *

Products/Services Sold *

Currently accept Visa and MasterCard? *

Bank Name *

Routing Number / ABA *

9 digits xxxxxxxxx

Account Number / DDA *

Where you want to deposit funds $

What type of Equipment would you like? *

Average Monthly Credit Card Sales Volume $ *

Average Transaction $ Amount *

Tax ID / EIN or ITIN # *

xx-xxxxxxx

*** IMPORTANT ***

Please list all owners with 25% or more ownership below

Owner #1 Name *

First

Last

Owner #1 Title *

Owner #1 Ownership Percentage (Must be 25% or more) *

Owner #1 Residence Address *

Owner #1 Email *

Owner #1 Mobile Phone *

Owner #1 Date of Birth *

Owner #1 Driver License Number *

Please be prepared to supply a copy of Driver License in Docusign

Additional Owner #2 Name

First

Last

Owner #2 Title

Owner #2 Ownership Percentage (Must be 25% or more) (copy)

Owner #2 Residence Address *

Owner #2 Email

Owner #2 Date of Birth

Owner #2 Driver License Number

Owner #3 Name

First

Last

Owner #3 Title

Owner #3 Ownership Percentage (Must be 25% or more)

Owner #3 Residence Address

Owner #3 Email

Owner #3 Date of Birth

Owner #3 Driver License Number

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