Full Name
*
Legal Business Name
*
DBA
*
Business Phone
*
Business Email
*
Cell Phone
*
Date of Birth
*
Business Owner - Date of Birth
Business Tax ID/EIN/ITIN
*
Business Owner SSN
Date Business Started
*
Business Street Address
*
City
*
State
*
Postal Code
*
Pricing Structure
*
Interchange +
Cash Discount
Flate Rate
Tiered
Discount Rate
Lease Amount
*
$
Type of Business Entity
*
LLC
Corporation
S Corp
Sole Propreitor
Partnership
Sales Agent Name
*
Incase direct add "NA"
Monthly Volume:
*
Highest Ticket Amount:
*
Average Ticket Amount:
*
Equipment/Terminal/Hardware
*
*How many terminals needed to run CC...Not how many for lease caps.
Special Instructions
*
Other Fees
*
Business Bank Name
*
Routing Number
*
Account Number
*
Fuel Card
WEX/Voyager
Upload Documents
PLEASE ATTACH FOLLOWING DOCUMENTS: 1. Voided Check 2. Drivers License