New Merchant Profile

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Merchant Profile

General Information

Business/ DBA Name *

Corporate/ Legal Name* *

Must Match IRS Tax Filing

Corporate Address *

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address (If Different Than Above)

Address Line 1

Address Line 2

City

State

Zip Code

Contact Name *

First

Last

Contact Phone *

Contact Business Email *

Email

Confirm Email

Fed Tax ID# *

State *

Date Started *

Business Structure

Sole Prop
Partnership
LLC/LLP
C Corp
S Corp
Govt
501c/Tax Ex

Owner (#1)

Name *

First

Last

Title *

Phone *

Email *

Email

Confirm Email

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Choose One

SSN
ITIN

Social Security # *

ITIN *

Date of Birth *

Additional Owners(2+)?

Yes
No

% of Ownership

Owner 2

Name *

First

Last

Title *

Phone *

Email *

Email

Confirm Email

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Choose One

SSN
ITIN

Social Security # *

ITIN *

Date of Birth *

Owner %

Additional Owners? (3+)

Yes
No

Owner 3

Name *

First

Last

Title *

Phone *

Email *

Email

Confirm Email

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Choose One

SSN
ITIN

Social Security # *

ITIN *

Date of Birth *

Owner %

Nature of Business

Business Type *

Restaurant
Retail
QSR
Supermarket
Non Profit
B2B
Mail/Telephone Order
Education
Utilities
Healthcare
Lodging
Government
Petroleum
Internet
Other

Do you accept EBT? *

Yes
No

Please Provide FNS Number *

Credit Card Statement Provided? *

Yes
No

Monthly Payment Card Volume

Highest Payment Card Ticket

Card ticket average

Salesperson

Upload Photo of a Voided Check

Drag & Drop Files, Choose Files to Upload

Upload Photo of Drivers License

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Upload Photo of Drivers License (#2)

Drag & Drop Files, Choose Files to Upload

Upload Photo of Drivers License (#3)

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