Legal Business Name *

Legal Address *

Legal City *

Legal State *

Legal Zip code *

IRS Tax Filing Name: *

Federal Tax ID *

How long have you been in business? *

Type of Business *

Product or Service Sold *

Business email *

customer service phone # *

Website

If you do NOT have a DBA (Doing Business As) name - Click Next

DBA Name

DBA Address - No PO Box #

DBA City

DBA State

DBA Zip

OWNERS, OFFICERS, AND MANAGEMENT (NO P.O. BOX #)

All beneficial owners (i.e. those with equity ownership equal to or greater than 25% and an individual who has significant managerial control in the entity) are required.

Title *

Percentage Ownership *

Has significant managerial control *

Yes

First Name *

Last Name *

Email *

Phone *

Date of birth *

Driver’s Lic #: *

Driver’s Lic State: *

OWNERS, OFFICERS, AND MANAGEMENT (NO P.O. BOX #)

All beneficial owners (i.e. those with equity ownership equal to or greater than 25% and an individual who has significant managerial control in the entity) are required.

Only complete if more than 1 owner.

Owner 2 Title:

Owner 2 Percentage Ownership

Owner 2 Has significant managerial control

Yes

Owner 2 First Name

Owner 2 Last Name

Owner 2 Email:

Owner 2 Phone

Owner 2 Date of birth

Owner 2 Driver’s Lic #:

Owner 2 Driver’s Lic State:

SERVICES QUESTIONNAIRE

What percentage of sales are Business to Business? *

What percentage of sales are Business to Consumer? *

You charge payment on the *

Does your business offer product guarantee or warrantee? *

Yes

If Yes to Warrantee

Refund Policy Within # of Days: *

Monthly Processing Volume

Average ticket $ (avg price per charge) *

High ticket $ (most expensive charge)

Max Monthly Volume $ *

Estimate your total monthly volume needed