Clover Merchant Application Intake

Business/Corporate Name *

Business Phone Number *

Business Email Address *

Address

Business Street Address *

City *

State *

Country *

Postal Code *

Business Structure Type *

Business Start Date *

EIN / Federal Tax ID Number *

If sole proprietorship use your social security number

DBA (Doing Business As) Name *

TIN Type *

Website

Upload EIN Letter (IRS CP575 or SS-4)

Upload Voided Check (Bank letter accepted) *

Upload Goverment Issued ID (Drivers License, Passport etc...

Click to upload

Owner 1 Title *

Owner 1 First Name *

Owner 1 Last Name *

Owner 1 personal Email *

Owner 1 Phone (mobile) *

Cell Phone Preferred

Customer Service Phone

Owner 1 Street Residence Address *

Owner 1 Residence City, State, ZIP *

Owner 1 SSN / SIN *

Owner 1 Equity Ownership % *

Owner 1 Date Of Birth *

Owner 1 Drivers License Number *

Provide the following information for each individual who owns,

directly or indirectly, 25% or more of the equity interest of your

business.

Number of Owners (25% or more) eac *

Owner 2 Full Name

Owner 2 Email

Owner 2 Mobile Phone

Owner 2 Equity Ownership %

EXAMPLE - 50%

Owner 2 SSN / SIN

Owner 2 Date of Birth

Owner 2 Residence Street Address

Owner 2 Residence City, State, ZIP

Owner 3 Full Name

Owner 3 Email

Owner 3 Mobile Phone

Owner 3 Equity Ownership %

Owner 3 SSN / SIN

Owner 3 Date of Birth

Owner 3 Residence Address

Owner 3 Residence City, State, ZIP

Owner 3 Drivers License Number

Owner 3 DL State / Province of Issuance

Owner 3 Ever Filed Bankruptcy?

Upload Owner 3 Drivers License

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